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LANDMARKS. 



MEDICAL AND SURGICAL. 



LUTHER HOLDEN, 

EX-PRESIDENT, MEMBER OF COUNCIL, AND MEMBER OF THE COURT OF 

EXAMINERS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND ; 

CONSULTING SURGEON TO SAINT BARTHOLOMEW'S AND 

THE FOUNDLING HOSPITALS. 



ASSISTED BY 

JAMES SHUTER, M.A. Camb., F.R.C.S., 

ASSISTANT SURGEON TO THE ROTAL FREE HOSPITAL ] LATE DEMONSTRATOR OF 

PHYSIOLOGY, AND LATE ASSISTANT DEMONSTRATOR OF ANATOMY, 

AT SAINT BARTHOLOMEW'S HOSPITAL. 

FROM THE THIRD ENGLISH EDITION, WITH ADDITIONS, 
BY 

WILLIAM W. KEEN, M.D., 

PROFESSOR OF ARTISTIC ANATOMY IN THE PENNSYLVANIA ACADEMY OF THE 

FINE ARTS J FORMERLY LECTURER ON ANATOMY IN THE 

PHILADELPHIA SCHOOL OF ANATOMY, ETC. 




W 



PHILADELPHIA: 
HENRY C. LEA'S SON & CO. 

1881. 



Or 






' Chirurgus mente prius et oculis agat quam manu armata. ,, 



Entered according to Act of Congress, in the year 1881, by 

II . C. LEA'S SON & CO., 

in the Office of the Librarian of Congress. All rights reserved. 



COLLINS, PRINTER. 



TO 



THE STUDENTS 



PAST AND PRESENT 



SALNT BARTHOLOMEW'S HOSPITAL 



THESE "LANDMARKS ARE 



. gefcicaM 



BY THEIR SINCERE FRIEND 



THE AUTHOR. 



PREFATORY NOTE. 



At the request of the publishers I have added 
as much practical matter to the text of Holden's 
admirable " Landmarks" as the space allowed 
would permit. All such additions are marked by 
brackets [ ]. 

Some twelve years ago I began this method of 
teaching that which I have ventured to call 
" Clinical Anatomy" (because it is precisely the 
anatomy that is needed at the bedside), using the 
living model more and more as the chief means 
of illustration. Increasing experience has but the 
more convinced me of its value, and any teacher 
who has once studied and then tried it faithfully 
will be very loath ever to give it up. In fact I 
think the living model is as essential in teaching- 
anatomy as is the cadaver or the skeleton. One 
such model the student always has — himself. 

WILLIAM W. KEEN, M.D. 

1729 Chestnut Street, 
Philadelphia, July 20, 1881. 

1* 



PREFACE 



TO 



THE THIRD EDITION. 



In the present Edition the author adheres to his 
decision not to introduce Diagrams. Additional 
experience more than ever convinces him that 
they Avould frustrate his original object, which is 
to teach Students the habit of making the eye and 
the hand work together, and to educate the " touch" 
upon the normal living body. 

Without such practical training, how can we 
reasonably expect to form a correct diagnosis when 
called upon to examine an injury or to detect a 
disease? In truth, the work is intended only for 
those who are desirous of acquiring the habit 
recommended. 

London: May, 1881. 



PREFACE 



THE FIRST EDITION 



These " Landmarks" have already appeared in 
Saint Bartholomew's Hospital Reports. They are 
now republished, with some additions, in the hope 
that they may be useful to others besides those for 
whom they were originally intended. 

My object has been to collect into a compact 
form the leading landmarks which help practical 
surgeons in their daily work. Those relating to 
the chest and abdomen have been ascertained, with 
as much precision as natural variations permit, by 
needles introduced in various directions. 

I have to express my acknowledgments to Mr. 
Walsham and to Dr. Godson for their contribu- 
tions. 

65 Goaver Street : March, 1876. 



LANDMARKS, 

MEDICAL AND SURGICAL, 



1. In clinical teaching, we often have occasion 
to point out, on the surface of the living body, 
what may be called " medical and surgical land- 
marks." By "landmarks" we mean surface- marks, 
such as lines, eminences, depressions, which are 
guides to, or indications of, deeper-seated parts* 
This practice is not only most useful, but abso- 
lutely necessary ; because many even advanced 
students of anatomy are not so ready as they 
ought to be in their recognition of parts when 
covered by skin. Students who may be familiar 
enough with bones, muscles, bloodvessels, or 
viscera in the dissected subject, are often sadly at 
fault when they come to put this knowledge into 
practice in the living. 

For instance, ask a student to put his finger on 
the exact place where he would feel for the head 
of the radius, the coracoid process of the scapula, 
the tubercle of the scaphoid bone in the foot ; 



12 LANDMARKS, MEDICAL AND SURGICAL. 

ask him to compress effectually one of the main 
arteries ; to chalk the line of its course ; to map 
on the chest the position of the heart and the 
several valves at its base ; to trace along the walls 
of the chest the outline of the lungs and pleura ; 
to point out the bony prominences about the 
joints, and their relative position in the different 
motions of the joints ; test him about the muscles 
and tendons which can be seen or felt as they 
stand out in relief or remain in repose ; let him 
introduce his finger into the several orifices of the 
body, and say what parts are accessible to the 
touch : — questions such as these, even a good 
anatomist, unaccustomed to deal with the living 
subject, might possibly find himself at a loss to 
answer. 

2. Object in View. — Our main object, there- 
fore, is to induce in students the habit of looking 
at the living body with anatomical eyes, and with 
eyes, too, at their fingers' ends. The value of this 
habit cannot be too highly estimated. Is it not of 
the utmost importance to an operating surgeon 
that he should have in his mind's eye the various 
structures of the body as they lie grouped, con- 
nected, and working together? Should he not try 
at least to see them with the same clearness and 
accuracy as if they were perfectly transparent ? 

Moreover, the habit of examining the living 



LANDMARKS, MEDICAL AND SURGICAL. 13 

body with "anatomical eyes" and "surgical fing- 
ers" teaches the eye and the hand to act together, 
and trains that delicate sense of touch, which every 
surgeon should possess. 

This habit is within easy reach of any one who 
has carefully dissected for himself, and learned 
what to feel for. Plates will not give him this 
knowledge. Let a student examine his own body 
with a skeleton before him. Better still that two 
should work thus together, each serving as a model 
to the other. 

Teachers of anatomy should follow the example 
of Sir C. Bell, who was in the habit of introducing, 
from time to time, a powerful muscular fellow to 
his class, "in order to show how much of the 
structure of the body, such as the articulations 
and the muscles, might be learned without actual 
dissection." 1 

At the same time, it is only fair to say that 
"landmarks" cannot always be defined with pre- 
cision. A considerable latitude must be allowed 
for natural variations in different persons. In 
some, their anatomy stands out beautifully clear ; 
in others it is masked by obesity. Selecting, there- 

1 Some pertinent remarks on this subject have been made 
by Mr. C. Heath in a pamphlet " On Anatomy in relation to 
Physic." 
2 



14: THE HEAD. 

fore, for study a moderately lean person, let us 
begin with the head. 

THE HEAD. 

3. Scalp; its Density. — The great toughness 
of the scalp, more especially at the back of the 
head, is owing to its intimate connection with 
the cranial aponeurosis, the scalp vessels and hair 
bulbs intervening. This density often obscures 
the diagnosis of tumors on the cranium. A tumor 
growing upon the head may be either above or 
below the aponeurosis of the scalp. If below, it 
will have a firm resisting feel, being bound down 
by the aponeurosis. Nevertheless its firmness 
and resistance may depend not simply on its con- 
finement beneath the aponeurosis, but on its 
having its origin within the skull. Look with 
suspicion, then, on every tumor on the head that 
will not readily permit you to move it about, so 
as to be sure of its connections prior to an attempt 
at extirpation. 

The scalp moves freely over the pericranium, 
to which it is very loosely connected by areolar 
tissue. When suppuration takes place in this 
tissue free incisions through the dense scalp must 
be made to let the pus out. 

4. Arteries of Scalp. — The supra-orbital artery 
can be felt beating just above the supra-orbital 



THE HEAD. 15 

notch, and traced for some way up to the forehead; 
the temporal (anterior branch) ascends tortuously 
about one inch and a quarter behind the external 
angular process of the frontal bone; the occipital 
can be felt near the middle of a line drawn from 
the occipital protuberance to the mastoid process; 
the posterior auricular, near the apex of the mas- 
toid process. All these arteries can be effectually 
compressed against the subjacent bone. 

5. Skullcap. — The skullcap is rarely quite 
s} T mmetrical. This want of symmetry is often 
obvious. It may occur in men highly gifted, as 
in the celebrated French anatomist Bichat. As 
to shape and relative dimensions, no two heads are 
exactly alike, any more than are two faces. It is 
beside my present purpose to go into the question 
of craniology more than to say that, although the 
cranium does not exactly follow the brain in all 
its eminences and depressions so as to be like a 
cast of its surface, yet it certainty indicates the 
dimensions of the great cerebral masses. The 
prominence of the frontal and parietal "eminences" 
and of the occipital region may be taken as a 
general indication of the development of the cor- 
responding lobes of the brain. To ascertain the 
relative proportions of these three regions, let a 
thread be passed from one meatus auditorius to 



16 THE HEAD. 

the other, across the frontal, parietal, and occipital 
eminences respectively. 

[Anterior Fontanelle. — At the junction of the 
sagittal and the coronal sutures in the new-born 
child is the anterior fontanelle, caused by the as 
yet incomplete ossification of the frontal and the 
parietal bones. It closes at about twelve to eigh- 
teen months of age. Its condition, as to whether 
it is a hollow or a hill, is important, for it shows 
the wasting of the fluids of the body, as in the 
summer diarrhoeas of children, or the redundancy 
of fluid within the skull, as in hydrocephalus. The 
pulse of a sleeping child can often be counted at 
the fontanelle by the eye alone.] 

Frontal Sinuses. — The "frontal sinuses" 
formed by the separation of the two tables of the 
skull vary much in size in different persons and 
at different periods of life. This fact has an impor- 
tant bearing on wounds in the forehead and on 
trephining in this situation. These "bumps" do 
not exist in children, because the tables of the 
skull do not begin to separate before puberty. 
From an examination of many skulls in the 
Hunterian Museum, I find that the absence of 
the "bumps," even in middle age, does not neces- 
sarily imply the absence of the sinuses, since they 
may be formed by a retrocession of the inner wall 
of the skull. In old persons, as a rule, when the 



THE HEAD. 17 

sinuses enlarge, it is by the encroachment of the 
inner table on the brain case. The inner wall of 
the skull here follows the shrinking brain. It is, 
therefore, important to bear in mind that an adult, 
and more especially an elderly person, may have 
a large fro'ntal sinus Avithout any external indica- 
tion of it. 

Neither does a very prominent bump neces- 
sarily imply the existence of a large sinus, or 
indeed of even a small one. The "bump" may 
be a mere heaping up of bone, a degradation as in 
some Australian skulls. 

Mastoid Process. — The mastoid process, which 
can be felt behind the ear, contains air-cells, to 
which the above observations may also be applied. 
["Mastoid disease," or suppuration in these cells, 
which, like the frontal sinuses, are lined by mucous 
membrane, causes pain, tenderness, and swelling in 
the process, and often demands early trephining to 
evacuate the pus.] 

Occipital Protuberance. — The occipital pro- 
tuberance, and the superior curved line, can be 
distinctly felt at the back of the head. The pro- 
tuberance is always the thickest part of the skull- 
cap, and more prominent in some than in others. 

The posterior inferior angle of the parietal 
bone, grooved by the lateral sinus, is on a level 

2* 



18 THE HEAD. 

with the zygoma, and a trifle more than one inch 
behind the front border of the mastoid process. 

Lines of Cerebral Sinuses. — A line drawn 
over the head from the root of the nose to the 
occipital protuberance corresponds with the supe- 
rior longitudinal sinus. Another line drawn from 
the occipital protuberance to the front border of 
the mastoid process corresponds with a part of the 
lateral sinus. 

Middle Meningeal Artery. — The trunk of the 
middle meningeal artery runs along the front lower 
corner of the parietal bone, about one inch and a 
half behind, and half an inch above, the external 
angular process of the frontal [or one inch and a 
half above the zygoma. This is a more definite 
measuring point vertically]. 

A straight line drawn from the front of one 
mastoid process to the other would pass through 
the middle of the condyles of the occiput, showing 
how nearly the skull is balanced on the top of the 
spine in the erect posture. 

6. Thickness of Skullcap. — The average 
thickness of the cap of an adult skull is about J- 
of an inch. The thickest part is at the occipital 
protuberance, where it is often J of an inch or 
more, even in an otherwise thin skull. The thin- 
nest part is at the temple, where it may be almost 
as thin as parchment. Every one in the habit of 



THE HEAD. 19 

making post-mortem examinations knows how 
much the skullcap differs in thickness in different 
persons and in different parts of same skull. In 
old persons it is often in some parts not thicker 
than a shilling, owing to absorption of the diploe. 
Another point of interest is that the inner plane 
of the cap is not always parallel with the outer. 
Hence, in applying the trephine this is not a bad 
rule — "Think that you are operating on the thin- 
nest skull ever seen, and thinner in one half of the 
circle than the other." 

7. Levels of the Brain. — The level of the an- 
terior lobes in front corresponds with a straight 
line drawn across the forehead, just above the eye- 
brows. The lower level of the anterior and middle 
lobes of the cerebrum corresponds with a line 
drawn from the external angular process of the 
frontal bone to the upper part of the meatus 
auditorius. Another line drawn from the meatus 
to the occipital protuberance corresponds with the 
lower level of the posterior lobe. The lower level 
of the cerebellum cannot be defined by external 
examination. It depends upon the extent to 
which the occipital fossse bulge into the nape of 
the neck; and this bulge varies in different skulls. 

[Ear. — The axis of the auditory canal is not 
directly transverse, but inward and forward, to- 
wards the opposite temple — a fact of importance in 



20 THE FACE. 

the use of instruments or of injections into the ear. 
The canal should always be inspected with care for 
abscesses, foreign bodies, or impacted wax, and, in 
cases of possible fracture at the base of the skull, 
for the escape of cerebro-spinal fluid. About one 
inch from the external meatus the canal is closed 
by the membrana tympani. This can be seen best 
through a speculum by reflected light from a hand 
or forehead mirror, but not uncommonly it can be 
seen without the speculum. To examine the au- 
ditory canal or the membrana tympani, the auricle 
must be pulled gently, but decidedly, upwards and 
backwards.] 

THE FACE. 

8. The approaches to the organs of the senses, 
their ever- varying expression, their nuuierous 
muscles, and their rich profusion of vessels and 
nerves, give the face great anatomical importance, 
which has a most valuable bearing, not only on 
the practice of surgery, but on the physiognomy 
of health, and in the diagnosis of disease. 

9. Foramina for Branches of fifth Nerve. — 
As a surgeon may be called upon to divide any 
one of the three chief branches of the fifth nerve 
upon the face, he looks with interest to the precise 
situations where they leave their bony foramina 



THE FACE. 21 

with their corresponding arteries. The supra- 
orbital notch or foramen can be felt about the 
junction of the inner with the middle third of 
the supraorbital margin. From this point a per- 
pendicular line drawn with a slight inclination 
outwards, so as to cross the interval between the 
two bicuspid teeth in both jaws, passes over the 
infraorbital and the mental foramina. The direc- 
tion of these two lower foramina looks towards the 
angle of the nose. [The canal in the lower jaw for 
the inferior dental nerve, it must be remembered, 
in persons who have lost the alveolar process by 
absorption, lies by so much nearer the upper 
margin of the jaw. A trephine must, therefore, 
in such persons be applied well above the middle 
of the bone, or the canal may be missed entirely.] 

10. Pulley for Superior Oblique Muscle. — 
By pressing the thumb beneath the internal an- 
gular process of the frontal bone, the cartilaginous 
pulley for the tendon of the superior oblique muscle 
can be distinctly felt. We should be careful not to 
interfere with this pulley in any operation about 
the orbit. 

11. Lower Jaw. — The working of the condyle 
of the jaw vertically and from side to side can be 
distinctly felt [and seen] in front of the ear. When 
the mouth is opened wide, the condyle advances 
out of the glenoid cavity on to the eminentia 



22 THE FACE. 

articularis, and returns into its socket when the 
mouth is shut. The muscle which causes this 
advance is the external pterygoid; and it gives the 
jaw a greater freedom of grinding motion. 

The posterior margin of the ramus of the lower 
jaw corresponds with a line drawn from the con- 
dyle to the angle. In opening abscesses in the 
parotid region, the knife should not be introduced 
behind this line for fear of wounding the external 
carotid artery. Punctures to any depth may be 
safely made in front of it. They are often neces- 
sary where inflammation of the parotid gland 
ensues after eruptive fevers, and runs on to suppu- 
ration. The swelling, tension, and pain are most 
distressing. Owing to the fibrous framework of 
the gland, the matter is not circumscribed, but 
diffused. One puncture is not enough. Three or 
more may be requisite. The blade of the knife 
should be held horizontally so as to be less likely 
to injure the branches of the facial nerve. We 
are not to be disappointed if no matter flows. 
The punctures give relief, and matter will proba- 
bly exude the next day. 

[Zygoma. — In front of the ear lies the zygoma, 
one of the most marked and important landmarks 
to the touch, and in lean persons to the eye. 

Seventh Nerve. — This nerve, after emerging 
from the stylo-mastoid foramen, passes into the 



THE FACE. 23 

parotid gland and is distributed to the facial 
muscles, its branches running towards the temple, 
the eye, the cheek, and the jaw. It can always 
readily be galvanized in facial palsy, etc., by 
placing one pole at the lobule of the ear and the 
other at the desired points of the face.] 

12. Parotid Duct. — A line drawn from the 
bottom of the lobe of the ear to midway between 
the nose and the mouth gives the course of the 
parotid duct. Opposite the second upper molar, 
the duct opens by a papilla into the mouth. The 
branch of the facial nerve which supplies the 
buccinator runs with the duct. 

13. Temporal and Facial Arteries. — The 
pulsation of the trunk of the temporal artery can 
be felt, between the root of the zygoma and the 
ear. This should be well known to and used by 
chloroformists. It is also a convenient pulse to 
feel in a sleeping patient. The facial artery can 
be distinctly felt as it passes over the body of the 
jaw at the anterior edge of the masseter; again 
near the corner of the mouth close to the mucous 
membrane ; and, lastly, hy the side of the ala 
nasi, up to the inner side of the tendo oculi. By 
holding the lips between the finger and thumb the 
coronary arteries are felt under the mucous mem- 
brane [and can be compressed here either by the 
finger and thumb, or by a spring clip, in hare-lip 



24 THE FACE. 

and other similar operations]. The facial vein 
does not accompany the tortuous artery, but runs 
a straight course from the inner angle of the eye 
to the front border of the masseter, just behind 
the artery. 

14. Eyelids and Eyes. — The opening between 
the eyelids varies in size in different persons; 
.hence more of the eyeball is seen in some than 
in others, and the eye appears larger. Although 
human eyes do vary a little in size, yet the actual 
difference is by no means so great as is generally 
supposed. The size of the fissure has much to do 
with the apparent size of the eye. Contrast the 
narrow fissure of the Chinese and Mongolian 
races, and the apparent smallness of their eyes 
with those of Europeans. As a rule the external 
angle of the lid is higher than the internal. When 
not exaggerated, it gives the face an arch and 
pleasing expression. 

Evert the lids to see the Meibomian glands; 
observe their perpendicular arrangement, in the 
substance of the tarsal cartilages. [Eversion of 
the upper lid is best done while the patient is 
looking down, by placing a pencil on the lid, next 
seizing the eyelashes, and then pushing the pencil 
gently downwards, while by the lashes the free 
border of the lid is lifted over it. In case of a 
suspected foreign bodjr, if it be not found on the 



THE FACE. 25 

lid, it must be remembered that it may easily be 
in the cornea and have been overlooked on the iris 
as a background. Oblique light will best reveal it 
if there.] 

The free borders of the lids are not bevelled, as 
described by J. L. Petit and most anatomists, "so 
as to form with the globe of the closed eye a 
triangular canal for the flow of the tears." On 
the contrary, it is easily seen that the lid margins, 
when closed, come into accurate contact. The 
plane is not exactly horizontal, but slightly in- 
clined upwards. 

Every time the eye is shut, the ball turns up- 
wards and inwards, so that the cornea is completely 
covered by the upper lid. This may be well seen 
by raising the lid of a sleeping infant ; also in 
cases of low fever when the lid is not completely 
closed. The upturning of the eye obviously clears 
the' cornea, and protects it from the light. 

A careful examination of the motion of the 
lower lid in the act of shutting the eye proves 
that it is a double motion. The lid is not only 
slightly raised, but drawn inwards about ^ of 
an inch. This second movement sweeps any 
particles of dust as well as moisture towards the 
inner canthus. 

15. Puncta Lachrymalia. — The puncta lach- 
rymalia are distinctly visible [as two little black 
3 



26 THE FACE. 

dots] at the inner angles of the lids. The lower 
punctum is larger and a little more external than 
the ripper, so that thej are not exactly opposite. 
The direction, too, of the puncta deserves notice. 
Their open mouths look a little backwards, ready 
to imbibe the tears. When their proper bearing 
is lost, as in facial - paralysis or by a cicatrix near 
the lid, the tears overflow the cheek. The length 
of the lachrymal canals is from three to four lines. 
The lower is a little shorter and wider than the 
upper. As each makes a little angle in its course, 
about a line from its orifice, the lid should be 
drawn outwards to straighten the canal when we 
introduce a probe. 

16. Lachrymal Sac. — To find the lachrymal 
sac, draw outwards the eyelids to tighten the 
tendo oculi, which crosses the sac a little above 
its middle. A knife introduced just below the 
tendon close to the edge of the orbit would enter 
the sac. The angular artery and vein would be 
on the inner side of the incision. A probe directed 
in a line with the inner edge of the orbit, i. e., 
downwards, outwards, and backwards, would pass 
down the nasal duct, and appear in the inferior 
meatus of the nose. 

The tendo oculi serves many purposes besides 
giving attachment to the cartilages and muscles of 
the lids. One purpose is said to be to pump the 



THE FACE. 27 

tears into the lachrymal sac. Place a finger on 
the tendon, and feel that it tightens every time 
the lids are closed. The tendon, being intimately 
connected to the sac, draws, as it tightens, the sac 
wall outwards and forwards, and in this way it 
may pump along the lachrymal canals any fluid 
collected at the angle of the eye. 

17. Nasal Duct. — The nasal duct is from six to 
eight lines long, and narrowest in the middle of 
its course. Its termination in the inferior meatus 
lies under the inferior spongy bone, about a quar- 
ter of an inch behind the bony edge of the nostril. 
The appearance of the orifice in the dry bone con- 
veys no idea of its size and shape in life; for it is 
diminished by a valve-like fold of mucous mem- 
brane, so that it becomes, in most cases, a mere 
slit, not exceeding a line in diameter. 

The facility with which instruments can be 
introduced into the nasal opening of the duct 
depends upon its position as well as its size. This 
position varies in different instances. Sometimes 
it opens directly into the roof of the inferior 
meatus, in which case the hole is large and round, 
so that tears readily run into the nose. In other 
instances the opening is situated on the outer wall 
of the meatus, and is then always such a narrow 
fissure as to be hardly discernible. The practical 
conclusion then is, that a probe can be easily in- 



28 THE FACE. 

troduced when the opening is in the roof of the 
meatus, but not without difficulty and laceration 
of the raucous membrane when on the outer wall. 
This difficulty indeed may be increased by the 
narrowness of the meatus, arising from an unusual 
curvature of the spongy bone. 

18. Nose and Nasal Cavities. — The line where 
the cartilages of the nose are attached to the nasal 
and superior maxillary bones can be traced with 
precision. The close connection of the skin to 
the cartilages admits of no stretching ; hence the 
acute pain felt in erysipelas and boils on the nose. 
The external aperture of the nose is always placed 
a little lower than the floor of the nostril, so that 
the nose must be pulled up before we can inspect 
its cavities. 

Looking into the nostrils, we find that the left 
is, in the majority of cases, narrower than the 
right, owing to an inclination of the septum 
towards the left. A communication sometimes 
exists between them, through a hole in the sep- 
tum, as in the case of the celebrated anatomist 
Hildebrandt. By stretching open the anterior 
nares we can get a view of the end of the inferior 
spongy bone. The middle spongy bone cannot be 
seen: its attachment to the ethmoid is high up, 
nearly opposite the tendo oculi. [With the head 
thrown well back this middle turbinated bone can 



THE FACE. 29 

be seen. It is important not to mistake these 
spongy bones for polypi.] The cavities are so 
much narrowed transversely by the spongy bones, 
that in the extraction of polypi it is better to 
dilate the blades of the forceps perpendicularly, 
and near the septum. 

[Lips. — The color of the vermilion border the 
doctor ought always, and even unconsciously, to 
notice, as a means of judging of the condition of 
the circulation and the character of the blood.] 

19. Mouth. — What can be seen and felt through 
the mouth? The upper surface of the tongue, 
"speculum primarum viarum" is a study in itself. 
We notice, on its under surface, a median furrow, 
on each side of which stands out the ranine vein, 
lying upon the prominent fibres of the lingualis. 
In the middle line of the floor of the mouth is the 
"frenum linguae," with the orifice of the duct of 
the submaxillary gland on each side of it. The 
gland itself can be detected immediately beneath 
the mucous membrane by feeling further back 
near the angle of the jaw, at the same time press- 
ing the gland upwards from below. 

The long ridge of mucous membrane on each 
side of the floor contains the sublingual glands. 

We can feel the attachment of the "genio-hyo- 
glossi" behind the symphysis of the jaw. The 
division of this attachment would enable a surgeon 

3* 



30 THE FACE. 

to draw the tongue more freely oat of the mouth 
in any attempt to remove carcinoma extending far 
back into its root. 

There is great difference in the shape of the hard 
palate; this difference depends upon the depth of 
the alveolar processes. In some it forms a broad 
arch ; in others it is narrow, and rises almost to a 
point like a Gothic arch, and materially impairs 
the tone of the voice. 

[Teeth. — In young children the question of the 
impending eruption of any tooth should always 
be settled by inspection. The secondary incisor 
teeth should be examined if any possibility of 
syphilis exist. Before giving any anaesthetic, arti- 
ficial teeth should invariably be removed.] 

Throat. — To examine the throat well, the nose 
should be held so as to compel breathing through 
the mouth. Thus the soft palate will be raised, 
the palatine arches widened, and the tonsils and 
the back of the pharynx fairly exposed. Pressing 
the tongue downwards, provided it be done very 
gently, is also of advantage. Eude treatment the 
tongue at once resists. The forefinger can be 
passed into the throat, beyond the epiglottis, as 
low as the bottom of the cricoid cartilage, and 
thus search the pharynx down to the top of the 
oesophagus, and the hyoid space (on each side) 
where foreign bodies are so apt to lodge. The 



THE FACE. 31 

greater corrm of the hyoid bone can be felt as a 
distinct projection on either side. In introducing a 
tube into the oesophagus the finger should keep the 
instrument well against the back of the pharynx 
so as to prevent its slipping into the larynx. 

Pass the finger between the teeth and the cheek 
and feel the anterior border of the coronoid process 
of the jaw. On the inner side of this process, 
between it and the tuberosity of the upper jaw, is 
a recess, where a deeply-seated temporal abscess 
might burst, or might be opened. Behind the last 
molar on the inner side of the upper jaw we can 
distinctly feel the hamular process of the sphenoid 
bone; also the lower part of the pterygoid fossa, 
and the internal pterygoid plate. Behind, and on 
the outer side of the last molar, can be felt part of 
the back of the antrum and of the lower part of 
the external pterygoid plate. 

On the roof of the mouth we can feel the pulsa- 
tion of the posterior palatine artery. Hemorrhage 
from this vessel can be arrested by plugging the 
orifice of the canal, which lies (not far from the 
surface) on the inner side of the last molar, about 
J of an inch in front of the hamular process. 

When the mouth is wide open, the pterygo- 
maxillary ligament forms a prominent fold readily 
seen and felt beneath the mucous membrane, be- 
hind the last molar teeth. A little below the 



32 THE FACE. 

attachment of this ligament to the lower jaw we 
can easily feel the gustatory nerve, as it runs 
close to the bone below the last molar tooth. The 
exact position of the nerve can be ascertained in 
one's own person by the acute pain on pressure. 
A division of the nerve, easily effected by a small 
incision, gives much temporary relief in cases of 
advanced carcinoma of the tongue. 

To feed a patient in spasmodic closure of the 
jaw, it is well to know that there is behind the 
last molar teeth a space sufficient for the passage 
of a small tube into the mouth. 

Antrum. — Lift up the upper lip and examine 
the front wall of the antrum. The proper place in 
which to tap it is above the second bicuspid tooth, 
about one inch above the margin of the gum. 

20. Posterior Nares. — A surgeon's finger 
should be familiar with the feel of the posterior 
nares, and of all that is within reach behind the 
soft palate. This is important in relation to the 
attachment of polypi, to plugging the nostrils, and 
to the proper size of the plug. In the examina- 
tion of this part of the back of the throat it is 
necessary to throw the head well back, because, 
in this position, nearly all the pharynx in front of 
the basilar process comes down below the level of 
the hard palate, and can be seen as well as felt. 
But when the skull is horizontal, i. e., at a right 



THE FACE. 33 

angle with the spine, the hard palate is on a level 
with the margin of the foramen magnum, and 
the parts covering the basilar process are con- 
cealed from view. 

The head then being well back, introduce the 
forefinger behind the soft palate, and turn it up 
towards the base of the skull. You feel the 
strong grip of the superior constrictor. Hooking 
the finger well forwards, you can feel the contour 
of the posterior nares. Their size depends upon 
the anterior, but rarely exceeds a small inch in 
the vertical diameter, and a small half-inch in 
the transverse. The plug for the posterior nares 
should not be larger than this. Their plane is not 
perpendicular, but slopes a little forwards. You 
can feel the septum formed by the vomer, and also 
the posterior end of the inferior spongy bone in 
each nostril. 

21. Tonsils. — Before taking leave of the throat, 
look well at the position of the tonsils between 
the anterior and posterior half arches of the palate. 
In a healthy state they should not project beyond 
the level of these arches. In all operations upon 
the tonsils, we should remember the close prox- 
imity of the external carotid artery to their outer 
side. Nothing intervenes but the pharjmgeal 
aponeurosis, and the superior constrictor of the 
pharynx. Hence the rule in operating on the 



34 THE FACE. 

tonsils, always to keep the point of the knife 
inwards. 

In troublesome hemorrhage from the tonsils, 
after an incision or removal, it is well to know 
that they are accessible to pressure if necessary 
by means of a padded stick, or even a finger. 

22. Features. — A word or two on the lines of 
the face as indicative of expression. Every one 
pays unconscious homage to the study of physiog- 
nomy when, scanning the features of a stranger, 
he draws conclusions concerning his intelligence, 
disposition, and character. Without discussing 
how much physiognomy is really worth, there 
can be no doubt that it is a mistake to place it in 
the same category as phrenology, since the latter 
lacks that sound base of physiology which no one 
can deny to the former. 

A person fond of observing cannot fail to have 
arrived at the conclusion that a man's daily calling 
moulds his features. Place a soldier, a sailor, a 
compositor, and a clergyman side by side, and who 
will not immediately detect a marked difference in 
their physiognomies? 

The muscles of the features are generally de- 
scribed as arising from the bony fabric of the face, 
and as inserted into the nose, the corners of the 
mouth, and the lips. But this description gives 
a very inadequate idea of their true insertion. 



THE NECK. 35 

They drop fibres into the skin all along their 
course, so that there is hardly a point of the face 
which has not its little fibre to move it. The 
habitual recurrence of good or evil thoughts, the 
indulgence in particular modes of life, call into 
play corresponding sets of muscles which, by pro- 
ducing folds and wrinkles, give a permanent cast 
to the features, and speak a language which all can 
understand, and which rarely misleads. Schiller 
puts this well when he says that "it is an admira- 
ble proof of infinite wisdom that what is noble 
and benevolent beautifies the human countenance ; 
what is base and hateful imprints upon it a revolt- 
ing expression." 

THE NECK. 

[Skin. — In no part of the body can the differ- 
ing thickness of the skin be more readily perceived 
than by pinching up a fold at the front and back 
of the neck.] 

23. Subcutaneous Veins. — Notice first the 
direction of the subcutaneous veins. The chief 
subcutaneous vein is the external jugular. Its 
course corresponds with a line drawn from the 
angle of the jaw to the middle of the clavicle, 
where it joins the subclavian. It is made more 
prominent by putting the sterno-mastoid into 



36 THE NECK. 

action, or by gentle pressure on the lower end of 
the vein. It is exceptionally joined by a branch 
which runs over the clavicle, and is termed 
"jugulo-cephalic." The anterior jugular gene- 
rally runs along the front border of the sterno- 
mastoid. [The condition of these veins should 
be examined in all diseases causing respiratory 
disturbance, especially dyspnoea. In case of tri- 
cuspid regurgitation there will be a venous pulse 
seen. The stethoscope will also reveal a venous 
hum or musical note over these veins in anaemia.] 

24. Parts in Central Line. Os-hyoides. — 
Immediately below and nearly on a level with 
the lower jaw we feel the body of the os-hyoides, 
and can trace backwards on each side the whole 
length of the cornua. They might easily be 
broken by the grasp of a garotter. Below the 
body of the os-hyoides is the gap above the 
thyroid cartilage. This gap corresponds with the 
anterior thyro-hyoid ligament and the apex of the 
epiglottis ; so that in cases of cut throat in this 
situation, nearly the whole of the epiglottis lies 
above the wound. 

Thyroid Cartilage. — The projection and depth 
of the notch in the thyroid cartilage, or "pomum 
Adami," varies in different persons. Between the 
notch and the hyoid bone there is a large bursa, 
which facilitates the play of the cartilage beneath 



THE NECK. 37 

the bone in deglutition. ■ The notch does not 
appear till puberty, and is throughout life much 
less distinct in the female than the male. The 
finger can trace the upper borders and cornua of 
the thyroid cartilage : its lower cornua can be felt 
by the side of the cricoid. 

On each side of the thyroid cartilage we can 
recognize the lateral lobes of the thyroid gland. 
On the upper and front part of the gland we can 
distinctly feel the pulsation of the superior thy- 
roid artery. This pulsation, coupled with the 
fact that the gland rises and falls with the larynx 
in deglutition, gives the best means of distinguish- 
ing a bronchocele from other tumors resembling it. 

Below the angle of the thyroid cartilage we 
feel the interval between it and the cricoid, which 
is occupied by the crico-thyroid membrane. In 
laryngotomy we cut through this membrane 
transversely close to the upper edge of the cricoid 
cartilage, in order that the incision may be as far 
as possible from the attachment of the vocal cords. 

25. Cricoid Cartilage. — The projection of the 
cricoid cartilage is a point of great interest to the 
surgeon, because it is his chief guide in opening 
the air-passages, and can always be felt even in 
infants, however young or fat. It corresponds to 
the interval between the fifth and sixth cervical 
vertebrae. The commencement of the oesophagus 
4 



38 THE NECK. 

lies behind it: here, therefore, a foreign substance 
too large to be swallowed would probably lodge, 
and might be felt externally. 

Again, a transverse line drawn from the cricoid 
cartilage horizontally across the neck would pass 
over the spot where the omo-hyoid crosses the 
common carotid. Just above this spot is the 
most convenient place for tying the artery. 

26. Those who have not directed their attention 
to the subject are hardly aware what a little 
distance there is between the cricoid cartilage 
and the upper part of the sternum. In a person 
of the average height sitting with the neck in an 
easy position, the distance is barely one inch and 
a half. When the neck is well stretched, about 
three-quarters of an inch more is gained. Thus, 
we have (generally) not more than seven or eight 
rings of the trachea above the sternum. None 
of these rings can be felt externally. The second, 
third, and fourth are covered by the isthmus of 
the thyroid gland. The trachea, it should be 
remembered, recedes from the surface more and 
more as it descends, so that, just above the 
sternum in a short fat-necked adult, the front of 
the trachea would be quite one inch and a half 
from the skin. 

27. Trachea. — In the dead subject nothing is 
more easy than to open the trachea : in the living, 



THE NECK. 39 

this operation may be attended with the greatest 
difficulties. In urgent dyspnoea you must expect 
to find the patient with his head bent forward, and 
the chin dropped, so as to relax as much as possi- 
ble the parts. On raising his head, a paroxysm of 
dyspnoea is almost sure to come on, threatening 
instant suffocation. The elevator and depressor 
muscles draw the trachea and larynx up and 
down with a rapidity and a force which may 
bring the cricoid cartilage within half an inch of 
the sternum. The great thyroid veins which 
descend in front of the trachea are sure to be 
distended. There may be a middle thyroid 
artery. In children the lobes of the thymus may 
extend up in front of the trachea, and the left 
vena innominata may cross it unusually high. 
Thus the air-tube may be covered by important 
parts which ought not to be cut. Considering 
all these possible complications, the least difficult 
and the best mode of proceeding is to open the 
trachea just below the cricoid cartilage ; and if 
more room be requisite, to pull down the isthmus 
of the thyroid gland, or in children to divide the 
cricoid itself. It is important that all the inci- 
sions be made strictly in the middle line, the 
"line of safety." 

28. Sterno-mastoid Muscle. — The sterno- 
mastoid muscle is the great surgical landmark of 



40 THE NECK. 

the neck. It stands out in bold relief when the 
head turns towards the opposite shoulder. Its 
inner border overlaps the common carotid, which 
can be easily compressed for a short time against 
the spine about the level of the cricoid cartilage. 
The artery extends (generally) as high as the 
upper border of the thyroid cartilage, and corre- 
sponds with a line drawn from the sterno-clavicu- 
lar joint to midway between the angle of the jaw 
and the mastoid process. 

Between the sternal origins of the sterno-mas- 
toid is the fossa above the sternum, more or less 
perceptible in different necks. As it heaves and 
sinks alternately, especially in distressed breath- 
ing, it was called by the old anatomists "fonti- 
culus gutturis." In beautiful necks, as seen in 
the " Venus," it is filled up by fat. 

Notice the interval between the sternal and 
clavicular origins of the sterno-mastoid. A knife 
introduced a very little way into this interval 
would wound, slanting inwards, the common 
carotid, slanting outwards, the internal jugular 
vein. These facts are of importance in perform- 
ing the subcutaneous section of the tendon of this 
muscle. 

29. Sterno-clavicular Joint.— Many impor- 
tant parts lie behind the sterno-clavicular joint. 
There is the commencement of the vena innomi- 



THE NECK. 41 

nata ; behind this comes the common carotid on 
the left side, and the division of the arteria 
innominata on the right. Deeper still, the apex of 
the lung rises into the neck. 

In a child the arteria innominata often lies in 
front of the trachea and divides a little higher 
than the joint : a point to be remembered in 
tracheotomy (27). 

30. Apex of Lung in the Neck. — The extent 
to which the apex of the lung rises into the neck 
is greater than is generally supposed. Many ob- 
servations in reference to this point lead to the 
conclusion that the lung rises behind the sterno- 
mastoid, on an average, one inch and a half above 
the clavicle ; in persons with long necks, as much 
as two inches. The apex of the lung and pleura 
is covered by the clavicular origin of the sterno- 
mastoid, the sterno-thyroid, and a part of the sca- 
lenus anticus. It is also crossed by the subclavian 
vessels in the first part of their course. As this 
cervical portion of lung is peculiarly liable to 
tubercular disease, it should always be carefully 
examined. Its condition may be ascertained by 
percussion near the sternal end of the clavicle. 

31. Supra- clavicular Fossa. — The hollow 
above the clavicle, between the sterno-mastoid 
and the trapezius, is very manifest in emaciation 
and old age. [Shrugging the shoulders makes it 

4* 



42 THE NECK. 

exceedingly pronounced.] Notice the termination 
here of the external jugular vein. In some necks 
only a small depression is visible, particularly 
when the trapezius has a broad insertion into the 
clavicle, and comes well forwards, so that its front 
border gives a graceful contour to the base of the 
neck. 

32. Subclavian Artery. — In the supra-clavicu- 
lar fossa, near the outer border of the sterno-mas- 
toid, and about one inch above the clavicle, we 
feel the pulsation of the subclavian artery. Here 
the artery lies upon the first rib, and can be effect- 
ually compressed. A little pressure is sufficient. 
But the pressure must be made in the right direc- 
tion, or the artery will be pressed off the rib 
instead of against it. The plane of the rib is such 
that the pressure, to be effectual, must be made in 
a direction downwards and a little inwards. It is 
best to stand behind the shoulder and make the 
pressure with one thumb. 

It is worth remembering that the outer border 
of the sterno-mastoid corresponds pretty nearly 
with the outer edge of the scalenus anticus, which 
is the surgical guide to the subclavian artery. [As 
the phrenic nerve passes over the scalenus anticus, 
it can now be readily located. If it is to be gal- 
vanized, one pole of the battery should be placed 
in this fossa and the other over the diaphragm.] 



THE CHEST. 43 

By pressing deeply at the upper part of the 
supra-clavicular fossa, the transverse process of 
the seventh cervical vertebra can be distinctly felt. 

In long and thin necks, a thin cord is percepti- 
ble, running nearly parallel with and just above 
the clavicle. It is the posterior belly of the omo- 
hyoideus. See it rising and falling in breathing, 
and making tense during inspiration that part of 
the cervical fascia which lies over the cervical 
portion of the lung. Thus it may be said to be in 
all respects a muscle of inspiration, co-operating 
with the sterno- mastoid and scaleni. In the lan- 
guage of transcendental anatomy, we may say 
that the central tendon of the omo-hyoid repre- 
sents a rudimentary cervical rib. Its posterior 
belly is analogous to a serration of the serratus 
magnus ; its anterior belly to a sterno-hyoid. 

THE CHEST. 

33. As a rule, the right half of the chest is 
slightly larger than the left. Of ninety- two per- 
sons of the male sex and good constitutions, 
seventy-one had the right side the larger ; eleven 
the left ; ten had both sides equal. The maximum 
of difference in favor of the right was one inch 
and a quarter. The measurements were made on 
a plane with the nipple. 



44 THE CHEST. 

34. Peculiarities in the Female.— The chest 
of the female differs from that of the male in the 
following points : — Its general capacity is less ; 
the sternum is shorter; the upper opening is 
larger in proportion to the lower ; the upper ribs 
are more movable, and therefore permit a greater 
enlargement of the chest at its upper part, in 
adaptation to the requirements of pregnancy. 

35. The top of the sternum is on a level with 
the second dorsal vertebra ; and the available 
space between the top of the sternum and the 
spine is hardly more than two inches. 1 

36. Parts behind first Bone of Sternum. — 
There is little or no lung behind the first bone 
of the sternum, the space being occupied by the 
trachea and large vessels as follows: — 

The left vena innominata crosses the sternum 
just below the upper border. Next come the 
great primary branches of the arch of the aorta. 
Deeper still is the trachea dividing into its two 
bronchi opposite the junction of the first and 

1 In several adult normal skeletons measured in the Hun- 
terian Museum, the average diameters of the upper opening of 
the chest were — antero-posterior, about 2\ inches; transverse, 
about 4£ inches. In the skeleton of O'Brien, the Irish giant, 
the antero-posterior diameter measures 4 inches, the trans- 
verse 64. 



THE CHEST. 45 

second bones of the sternum. Deepest of all is 
the oesophagus. 

About one inch from the upper border of the 
sternum is the highest part of the aorta, which lies 
on the bifurcation of the trachea. 

37. The course of the arteria innominata corre- 
sponds with a line drawn from the middle of the 
junction of the first with the second bone of 
the sternum, to the right sterno-clavicular joint. 
When the artery rises higher than usual into the 
neck, its pulsation can be felt in the fossa above 
the sternum. 

38. Rules for counting the Ribs. — In fat 
persons it is often difficult to count the ribs; 
hence the following rules may be useful : — 

a. The finger passed down from the top of the 
sternum soon comes to a transverse projection, 
slight, but always to be felt, at the junction of 
the first with the second bone of the sternum. 
This corresponds with the level of the cartilage of 
the second rib. 

b. The nipple of the male is placed, in the great 
majority of cases, between the fourth and the fifth 
ribs, about three-quarters of an inch external to 
their cartilages. 

c. The lower external border of the pectoralis 
major corresponds with the direction of the fifth 
rib. 



46 THE CHEST. 

d. A line drawn horizontally from the nipple 
round the chest cuts the sixth intercostal space 
midway between the sternum and the spine. This 
is a useful rule in tapping the chest. 

e. When the arm is raised, the highest visible 
digitation of the serratus magnus corresponds 
with the sixth rib. The digitations below this 
correspond respectively with the seventh and 
eighth ribs. 

/. The scapula lies on the ribs from the second 
to the seventh, inclusive. 

g. The eleventh and twelfth ribs can be felt 
even in corpulent persons, outside the erector 
spinas, sloping downwards. 

h. One should remember the fact that the 
sternal end of each rib lies on a lower level than 
its corresponding vertebra. For instance, a line 
drawn horizontally backwards from the middle 
of the third costal cartilage at its junction with 
the sternum, to the spine, would touch the body, 
not of the third dorsal vertebra, but of the sixth. 
Again, the end of the sternum would be on about 
the level of the tenth dorsal vertebra. Much 
latitude must be allowed here for variation in the 
length of the sternum, especially in women. 

39. Interval below Clavicle. — Immediately 
below the clavicle we recognize the triangular 
interval between the pectoralis major and the 



THE CHEST. 47 

deltoid. This space varies in different cases, de- 
pending on the distance between the muscles. It 
is important as a guide to the coracoid process 
and the axillary arterj^. In a case of injury to 
the shoulder, to ascertain whether the coracoid 
process is broken, carry the arm outwards, to put 
the deltoid and pectoral muscles on the stretch, 
and make manifest the space between their oppo- 
site borders. Pressing the thumb into the space 
we can feel the inner side of the coracoid process, 
the apex being under the fibres of the deltoid ; 
thus it is easy to ascertain whether it be broken. 
Moreover, this space corresponds with the line of 
the axillary artery ; here its pulsation can be dis- 
tinctly felt, and here it can be compressed (but not 
easily, or for long) against the second rib. 

40. Internal Mammary Artery. — The line 
of the internal mammary artery runs perpendicu- 
larly behind the cartilages of the ribs, about half 
an ' inch from the sternum. The perforating 
branch through the second intercostal space is 
generally the largest. 

41. Outline of Heart on Chest- wall.— To 
have a general idea of the form and position of 
the heart, map its outline on the wall of the chest 
as follows : — 

a. To define the base draw a transverse line 
across the sternum corresponding with the upper 



48 THE CHEST. 

borders of the third costal cartilages: continue the 
line half an inch to the right of the sternum and 
one inch to the left. 

/;. To find the apex, mark a point about two 
inches below the left nipple, and one inch to its 
sternal side. This point will be between the fifth 
and sixth ribs. 

c. To find the lower border (which lies on the 
central tendon of the diaphragm), draw a line, 
slightly curved downwards, from the apex across 
the bottom of the sternum (not the ensiform 
cartilage) as far as its right edge. 

d. To define the right border (formed by the 
right auricle), continue the last line upwards with 
an outward curve, so as to join the right end of 
the base. 

e. To define the left border (formed by the left 
ventricle), draw a line curving to the left, but not 
including the nipple, from the left end of the 
base to the apex. 

Such an outline (seen in the cut, below, with the 
angles rounded off) shows that the apex of the 
heart points downwards and towards the left, the 
base a little upwards and towards the right; that 
the greater part of it lies in the left half of the 
chest, and that the only part which lies to the 
right of the sternum is the right auricle. A needle 
introduced in the third, the fourth, or the fifth 



THE CHEST. 



49 



right intercostal space close to the sternum would 
penetrate the lung and the right auricle. 



Fig. l. 




Outline of the Heart, its Valves, and the Lungs. 



A needle passed through the second intercostal 
space, close to the right side of the sternum, 
would, after passing through the lung, enter the 
pericardium and the most prominent part of the 



bulge of the aorta. 



50 THE CHEST. 

A needle passed through the first intercostal 
space, close to the right side of the sternum, would 
pass through the lung and enter the superior vena 
cava above the pericardium. 

42. The best definition of that part of the pre- 
cordial region which is less resonant on percus- 
sion, was given by Dr. Latham years ago in his 
"Clinical Lectures." "Make a circle of two inches 
in diameter round a point midway between the 
nipple and the end of the sternum. This circle 
will define, sufficiently for all practical purposes, 
that part of the heart which, lies immediately 
behind the wall of the chest, and is not covered 
by lung or pleura." 

Apex of the Heart. — The apex of the heart 
pulsates between the fifth and sixth ribs, two 
inches below the nipple, and one inch to its 
sternal side. The place and extent, however, of 
the heart's impulse, vary a little with the position 
of the body. Of this any one may convince him- 
self by leaning forwards, backwards, on this side 
and on that, feeling, at the same time, the heart. 
Inspiration and expiration also alter the position 
of the heart. In a deep inspiration it may descend 
half an inch, and can be felt beating at the pit of 
the stomach. 

43. Valves of the Heart, — The aortic valves 
lie behind the third intercostal space, close to the 
left side of the sternum. 



THE CHEST. 51 

The pulmonary valves lie in front of the aortic 
behind the junction of the third costal cartilage, 
on the left side, with the sternum. 

The tricuspid valves lie behind the middle of 
the sternum, about the level of the fourth costal 
cartilage. 

The mitral valves (the deepest of all) lie behind 
the third intercostal space, about one inch to the 
left of the sternum. 

Thus these valves are so situated that the 
mouth of an ordinary sized stethoscope will cover 
a portion of them all, if placed over the sternal 
end of the third intercostal space, on the left side. 
All are covered by a thin layer of lung ; therefore 
we hear their action better when the breathing is 
for a moment suspended. 

[Where to Auscult the Valves of the 
Heart. — The valves being so close together, it is 
evident that, to discriminate the sound of one from 
that of the others, we must be able to auscult 
them separately ; and accordingly we follow the 
diverging course of the blood-currents they trans- 
mit. Hence, 

The aortic valve is best ausculted over the 
second intercostal space at the right border of the 
sternum ; it can also be heard over the aorta in 
the back, from the third to the ninth dorsal spines, 
especially if there be any murmur ; 



52 THE CHEST. 

The pulmonary valve, over the second space at 
the left border of the sternum; 

The tricuspid valve, over the middle of the 
sternum above the ensiform cartilage ; and 

The mitral valve, over the apex of the heart.] 

44. Outline of the Lungs. — Now let us trace 
on the chest the outline of the lungs, with as 
much precision as their expansion and contraction 
in breathing permit. (See the cut, p. 49.) 

45. The apex of each lung rises into the neck 
behind the sternal end of the clavicle and sterno- 
mastoid muscle as much as an inch and a half: in 
females rather higher than in males (30). From 
the sternal ends of the clavicles the lungs con- 
verge, so that their thin edges almost meet in the 
mesial line on a level with the second costal car- 
tilage. Thus there is little or no lung behind the 
first bone of the sternum. From the level of the 
second costal cartilage to the level of the fourth, 
the margins of the lungs run parallel, or nearly 
so, close behind the middle of the sternum: con- 
sequently their thin edges overlap the great vessels 
and valves at the base of the heart. 

Below the level of the fourth costal cartilage 
the margins of the lungs diverge, but not in an 
equal degree. The margin of the right corre- 
sponds with the direction of the cartilage of the 
sixth rib : the margin of the left, being notched 



THE CHEST. 53 

for the heart, runs behind the cartilage of the 
fourth. A line drawn perpendicularly from the 
nipple would find the lung margin about the 
lowest part of the sixth rib. Laterally, i. e., in 
the axillary line, the lung margin comes down as 
low as the eighth rib : posteriorly, i. e., in the 
dorsal or scapular line, it descends as low as the 
tenth. 

It should be remembered that, in a deep inspira- 
tion, the lung margins descend about one inch and 
a half. 

In children the lungs are separated in front by 
the thymus gland. Allowance should be made 
for this. About the approach of puberty the 
thymus disappears. 

46. Anterior Mediastinum. — The direction 
of the anterior mediastinum is not straight down 
the middle of the sternum, but slants a little to 
the left, owing to the position of the heart. The 
right pleural sac generally encroaches a little upon 
the left, behind the middle of the sternum. A 
needle introduced through the middle of the ster- 
num opposite the third or the fourth rib would 
go through the right pleura. 

47. Reflection of Pleura. — The reflection of 
the pleura from the wall of the chest on to the 
diaphragm corresponds with a sloping line drawn 
from the bottom of the sternum over the cartilages 

5* 



54 THE BACK. 

of the ribs down to the lower border of the last 
rib. 

Since the pleura lines the inside of the last rib, 
a musket ball or other foreign body, loose in the 
pleural sac, and rolling on the diaphragm, might 
fall to the lowest part of the sac, which would be 
between the eleventh and twelfth ribs. The ball 
might be extracted here. The chest might also 
be tapped here, but not with a trocar, since a 
trocar would penetrate both layers of pleura, and 
go through the diaphragm into the abdomen. 

The operation should be done cautiously, by an 
incision beginning about two inches from the 
spine, on the outer border of the "erector spinas," 
on a level between the spines of the eleventh and 
twelfth dorsal vertebras. The intercostal artery 
will not be injured if the opening be made below 
the middle of the space, which is very wide. 1 



THE BACK. 

48. Median Furrow. — In a muscular man, a 
furrow, caused by the prominence of the erector 
spinas on each side, runs down the middle of the 

1 Special experiments upon this subject were made many- 
years ago by the late Professor Quekett in the work-rooms 
of the College of Surgeons. 



THE BACK. 55 

back. The lower end of the farrow corresponds 
with the interval between the spine of the last 
lumbar and that of the first sacral vertebra. [It 
must be observed that in the skeleton and the 
body furrows and prominences, hills and hollows, 
are, as a general rule, reversed. Bony projections 
in the skeleton, as a rule, are for muscular origins. 
As, at a little distance from the origin, the mus- 
cular bellies swell out, such prominences lie at the 
bottom of depressions. But when long sickness 
wastes the soft parts, the form of the skeleton 
reappears, and such bony prominences then be- 
come the favorite seats of bedsores.] 

49. Spines of Vertebrae. — A little friction 
with the fingers down the backbone will cause 
the spines of the vertebras to be tipped with red, 
so that they can be easily counted, and any devia- 
tion from the straight line detected. Still it is 
worth remembering that the spine of the third 
dorsal is on a level with the commencement of the 
spine of the scapula — that the spine of the seventh 
dorsal is on a level with the inferior angle of the 
scapula — that the spine of the last dorsal is on a 
level with the head of the last rib. 

Division of the Trachea. — The division of 
the trachea is opposite the spine of the third, in 
some cases the fourth, dorsal vertebra. In front 



56 THE BACK. 

this division is on the level of the junction of the 
first with the second bone of the sternum. 

The root of the spine of the scapula is marked 
by a slight dimple in the skin. This is on a level 
with the third intercostal space. A stethoscope 
placed on the inner side of the dimple would 
cover the bronchus, more especially the right, 
since it is nearer to the chest wall. 

Make a man lean forwards, with his arms folded 
across the chest; this will make prominent the 
spines of the vertebras. The lower border of the 
trapezius will guide you to the spine of the twelfth 
dorsal vertebra. 

50. The place where the kidney is most ac- 
cessible to pressure is below the last rib, on the 
outer edge of the erector spinas. 

51. The highest part of the ilium is about the 
level of the fourth lumbar spine. The best in- 
cision for opening the descending colon is in a 
slightly sloping line beginning at the outer edge 
of the erector spinas, midway between the crest of 
the ilium and the last rib, and continued across 
the flank for three inches or more, according to 
the amount of subcutaneous fat. [This ilio-costal 
space varies very much in its vertical measure- 
ment. I have seen it only a finger's breadth, and 
again a whole hand's breadth. The line of the 
colon passes through it vertically about half an 



THE BACK. 57 

inch behind the middle of the crest of the ilium 
(Heath).] 

52. In the pit of the neck we can feel the tra- 
pezius and the ligamentum nuchas. By pressing 
deeply we detect the forked and prominent spine 
of the second cervical vertebra. 

53. The spines of the third, fourth, and fifth 
cervical vertebras recede from the surface to per- 
mit free extension of the neck, and cannot often 
be felt. But the spines of the sixth and seventh 
(v. prominens) stand out well. 

54. Notice that most of the spines of the dorsal 
vertebrae, owing to their obliquity, do not tally 
with the heads of their corresponding ribs. Thus, 
the spine of the second dorsal corresponds with 
the head of the third rib ; the spine of the third 
dorsal with the head of the fourth rib, and so on 
till we come to the eleventh and twelfth dorsal 
vertebras, which do tally with their correspond- 
ing ribs. All this, however, is best seen in the 
skeleton. 

55. The spines of the vertebras may be useful as 
landmarks indicative of the levels of important 
organs. I have therefore arranged them in a 
tabular form, thus : — 



58 



THE BACK. 



Tabular Plan of Parts opposite the Spines 
of the Vertebra. 

7th. Apex of lung : higher in the female than in 
the male. (30) 

1st. 

2d. 

3d. Aorta reaches spine. Apex of lower lobe of 
lung. Angle of bifurcation of trachea. (49) 

4th. Aortic arch ends. Upper level of heart. 

5th. 

6th. 

7th. 

8th. Lower level of heart. Central tendon of dia- 
phragm. 

9th. (Esophagus and vena cava through diaphragm. 
Upper edge of spleen. 

10th. Lower edge of lung. Liver comes to surface 
posteriorly. Cardiac orifice of stomach. 

11th. Lower border of spleen. Renal capsule. 

12th. Lowest part of pleura. Aorta through dia- 
phragm. Pylorus. 

1st. Renal arteries. Pelvis of kidney. (83) 

2d. Termination of spinal cord. Pancreas. Duo- 
denum just below. Receptaculum chyli. 

3d. Umbilicus. Lower border of kidney. 

4th. Division of aorta. (65) Highest part of ilium. 

5th. 



56. Origins of the Spinal Nerves. — It is 

useful to know opposite what vertebrae the spinal 
nerves in the different regions arise from the spinal 
cord. They arise as follows: — 



THE BACK. 59 

The origins of the eight cervical nerves corre- 
spond to the interval between the occiput and the 
sixth cervical spine. 

The origins of the first six dorsal nerves corre- 
spond to the interval between the sixth cervical 
and the fourth dorsal spines. 

The origins of the six lower dorsal nerves cor- 
respond to the interval between the fourth and the 
eleventh dorsal spines. 

The origins of the five lumbar nerves correspond 
to the interval between the eleventh and twelfth 
dorsal spines. 

The origins of the five sacral nerves correspond 
to the spines of the last dorsal and the first lum- 
bar vertebras. 



Fig. 2. — Diagram and Table showing the Approximate Relation to the 
Spinal Nerves of the Various Motor, Sensory, and Reflex Functions of 
the Spinal Cord. {From anatomical and pathological data.) From Gower. 



St. -mastoid 
Trapezius 



Diaphragm 




^-Abductors 

J Extensors(?). 
~] Flexors, knee(?) 

I 
Muscles of leg 
moving foot 

Perineal and Anal 
muscles 



Neck and Scalp 

Neck and Shoulder 
Shoulder 

)>Arm 
Hand 



Front of Thorax 



Ensiform ares 



Abdomen 
(Umbilicus 10th) 



?But 



ttock, upper 
part 

Groin and scrotum 
J (front) 
"1 f outer side 



-Thigh -{ front 



inner side 
\ Leg, inner side 
f Buttock, lower 
• part 



Back of Thigh 
Leg ^ Except 
, and \ inner 
J LFoot ) part 
} Perineum and 
> Anus 



I Skin from coccyx 
> to anus 



J>Scapnlar 



Epigastric 



^Abdominal 



Cremasteric 



Y Knee-jerk 



Gluteal 






Foot-clonus 
Plantar] 



THE BACK. 



61 



57. Movements of the Spine.— The move- 
ments of which the spine is capable are threefold : 
1, flexion and extension ; 2, lateral inclination ; 3, 
torsion. Flexion and extension are freest between 
the third and sixth cervical vertebrae, between 
the eleventh dorsal and the second lumbar, and 
between the last lumbar and the sacrum. This is 
well marked in severe cases of opisthotonos, where 
the body is supported on the back of the head and 
heels. 1 

[Fig. 3. 




Opisthotonos. After Bell.] 



Still better may it be observed when a mounte- 
bank bends backwards, and touches the ground 
with his head. 



1 See a beautiful illustration of this in Sir C. Bell's "Anat- 
omy of Expression," p. 160. 
6 



62 THE BACK. 

The lateral movement is freest in the neck and 
the loins. 

The movement of torsion or rotation round 
its own axis may be proved by the following 
experiment : Seated upright, with the back and 
shoulders well applied against the back of a chair, 
we can turn the head and neck as far as 70°. 
Leaning forwards so as to let the dorsal and 
lumbar vertebras come into play, we can turn 30° 
more. 

[The atlo-axoid movement amounts to 25° to 
each side, the remaining cervical vertebras give 
45° more, making 70° in the neck ; the dorso- 
lumbar movement is about 30° ; to which the hips 
add from 65° to 80°, or a total rotation of 165° 
to 180°. For purposes of observation, we gain, in 
addition to this, about 70° more for the eyeball, so 
that, posteriorly, the field of vision right and left 
overlaps very largely.] 

58. Position and Motions of Scapula. — There 
are a few points worthy of observation about the 
scapula. It covers the ribs from the second to the 
seventh inclusive. We can feel its superior angle 
covered by the trapezius. The inferior angle is 
covered by the latissimus dorsi, which keeps it 
well applied against the ribs in the strong and 
athletic; but in weak and consumptive persons the 



THE BACK. 63 

lower angles of the scapulae project like wings — 
hence the term "scapulae alatae." 

A line drawn horizontally from the spine of the 
sixth dorsal vertebra over the inferior angle of the 
scapula gives the upper border of the latissimus 
dorsi. Another line drawn from the root of the 
spine of the scapula to the spine of the last dorsal 
vertebra gives the lower border of the trapezius, 
which stands a little in relief. 

59. The sliding movement of the scapula on 
the chest can be properly understood only on the 
living subject. It can move not only upwards 
and downwards as in shrugging the shoulders — 
backwards and forwards as in throwing back the 
shoulders — but it has a rotatory movement round 
a movable centre. This rotation is seen while the 
arm is being raised from the horizontal to the 
vertical position, and is effected by the co-opera- 
tion of the trapezius with the serratus magnus. 
The glenoid cavity is thus made to look upwards, 
the inferior angle slides forwards, and is well held 
under the latissimus dorsi. 

60. For the medical examination of the back, 
the patient should sit with the arms hanging 
between his thighs, to lower the scapulae as much 
as possible. In this position the spine of the 
scapula corresponds (nearly) with the fissure be- 
tween the upper and lower lobes of the lung ; the 



64 THE ABDOMEN. 

apex of the lower lobe being about the level of the 
third rib. 

[Usually I prefer to have the arms folded 
across the chest — obviously the better position for 
women ; and it uncovers the back rather better. 

The remarkable mobility of the scapula is best 
seen by contrasting this position with the place of 
the scapula when the shoulders are thrown well 
back. In this last position the lower angles of the 
scapulae will be two or three inches apart, while in 
the former this interval measures from twelve to 
sixteen inches. Moreover so soon as the arm is 
lifted from the trunk at an angle of 30° or 40° 
and long before it reaches the horizontal line the 
scapula begins to move. This mobility of the 
scapula explains readily the great range of move- 
ment, and therefore the usefulness of the arm, in 
cases of ankylosis of the shoulder joint.] 

THE ABDOMEN. 

The student is assumed to be familiar with 
the conventional lines dividing the abdomen into 
regions. 

61. Abdominal Lines.— The linea alba, or cen- 
tral line of the abdomen, marks the union of the 
aponeuroses of the abdominal muscles. It runs 
from the apex of the ensiform cartilage to the 



THE ABDOMEN. 65 

sympl^sis pubis. As this line is the thinnest and 
least vascular part of the abdominal wall, we make 
our incision along it in ovariotomy [Csesarean sec- 
tion and most other operations on the abdominal 
and pelvic viscera] and in the high operation of 
lithotomy; in it, we tap the abdomen in ascites, 
and the distended bladder in retention of urine. 

The so-called "linea semilunaris," at the outer 
border of the sheath of the rectus, corresponds 
with a line, drawn slightly curved (with the con- 
cavity towards the linea alba), from the lowest 
part of the seventh rib to the spine of the pubes. 
This line would be in an adult about three inches 
from the umbilicus; but in an abdomen distended 
by dropsy or other cause, the distance is increased 
in proportion. [These lines of adhesion in the 
abdominal wall limit extravasations, emphysema, 
etc., between their layers.] 

It is important to know the position of the 
"lineas transversae," or tendinous intersections 
across the rectus abdominis. There are rarely any 
below the umbilicus, and generally three above it. 
The first is about the level of the umbilicus. The 
second is about four inches higher — that is, about 
the level of the lowest part of the tenth rib. These 
are the principal lines, and they divide the upper 
part of each reotus into two nearly quadrilateral 
portions, an upper and a lower ; of these, those 

6* 



C)Q THE ABDOMEN. 

on the right side are a trifle larger than on the 
left. We see these muscular squares pretty plainly 
in some athletic subjects. Much more frequently 
we see them, too much exaggerated, on canvas 
and in marble. Artists are apt to exaggerate 
them and make the front of the belly too much 
like a chess-board. It is lucky for them that all 
the world do not see with anatomical eyes. 

A familiarity with the shape and position of 
these divisions of the rectus is of importance, lest 
we should, in ignorance, make a mistake in our 
diagnosis. A spasmodic contraction of one of these 
divisions, particularly the upper, or a collection 
of matter within its sheath, has been frequently 
mistaken for deep-seated abdominal disease. 

In the erect position, the anterior superior 
spines of the ilia are a little below the level of the 
promontory of the sacrum. The bifurcation of 
the aorta is on about the level of the highest part 
of the crest of the ilium. 

62. Umbilicus. — The umbilicus is not midway 
between the ensiform cartilage and the pubes, but 
rather nearer to the pubes. In all cases it is situ- 
ated above the centre of a man's height. It is a 
vulgar error to say that when a man lies with 
legs and arms outstretched, and a circle is drawn 
round him, the umbilicus lies in the centre of it. 



THE ABDOMEN. 67 

This central point is in most persons just above 
the pubes. 

[From the vertex to the umbilicus, the whole 
height being taken as the unit of measurement, is 
.550 at birth, i. e., the mid-point is above the navel. 
At two years it is at the navel, and gradually falls 
as the legs grow longer, until, at thirty, the mid- 
point is just below the pubes in men (half an inch) 
and just above it in women. Moreover, while at 
three to five years of age the whole height is equal 
to the distance between the outstretched finger- 
tips, before that age it is somewhat greater, and in 
adult life is much less.] 

In very corpulent persons two deep transverse 
furrows run across the abdomen. One runs across 
the navel and completely conceals it. The other is 
lower down, just above the fat of the pubes. In 
tapping the bladder above the pubes in such a 
case, the trocar should be introduced where this 
line intersects the linea alba. 

Although the position of the umbilicus varies 
a little in different persons, as the abdomen is 
unusually protuberant or the reverse, still, as a 
general rule, it is placed about the level of the 
body of the third lumbar vertebra. Now, since 
the aorta divides a little below the middle of the 
fourth lumbar, it follows that the best place to 
apply pressure on this great vessel is one inch be- 



68 THE ABDOMEN. 

low the umbilicus, and slightly to the left of it (65). 
That the aorta cao, under favorable circumstances, 
be compressed under chloroform sufficiently to 
cure an aneurism below it, is proved by recorded 
cases, and by none more effectually than by a case 
related in the second volume of the "Eeports of 
St. Bartholomew's Hospital." 

It may be asked, why not apply pressure on the 
aorta above the umbilicus? The answer is, that 
the aorta above the umbilicus is farther from the 
surface, and is, moreover, covered by important 
structures upon which pressure would be danger- 
ous. 

[The umbilicus is a point of fusion of all the 
tissues of the abdominal wall. Hence, it becomes 
a most valuable guide as to our position when 
attacking tumors, etc., in the abdomen. Attempt 
to sweep the finger under the umbilicus: if 
through the abdominal wall and upon the tumor, 
the finger will meet with no obstacle other than 
adhesions, which can be destroyed ; if, on the con- 
trary, still in the thickness of the abdominal wall 
(and it is not always easy to distinguish this in any 
other way), the finger will be absolutely arrested 
at the navel, and no force will carry it further. 

The umbilicus being the remains of an opening 
into the belly, when stretched by ascites, as the 
fluid can insinuate itself everywhere, it usually 



THE ABDOMEN. 69 

bulges out considerably; but in tumors this cannot 
be the case. 

Again, it affords passage to the contents of the 
belly not uncommonly, and so we have umbilical 
hernias; and sometimes ovarian fluids, pus in peri- 
tonitis, and entozoa escape here. 

It is also an important point for measurements, 
sometimes used in fractures and dislocations of the 
hip and femur, and in fractures of the anterior 
superior spines, and always in measuring the size 
of tumors from it to the ensiform, the pubes, and 
the two iliac spines. 

The umbilicus is always much deeper and wider 
in women than in men.] 

63. Parts behind Linea Alba. — Let us next 
consider what viscera lie immediately behind the 
linea alba. For two or three fingers' breadth 
below the ensiform cartilage there is the left lobe 
of the liver, which here crosses the middle line. 
Below the edge of tjie liver comes the stomach, 
more or less in contact with the linea alba, 
according to its degree of distension. In extreme 
distension the stomach pushes everything out of 
the way, and occupies all the room between the 
liver and the umbilicus. "When empty and con- 
tracted, it retreats behind the liver, and lies flat in 
front of the pancreas at the back of the abdomen; 
thus giving rise to the hollow termed the "pit of 



70 THE ABDOMEN. 

the stomach." But as the stomach distends, it 
makes a considerable fulness where there was a 
pit. The middle of the transverse colon lies above 
the umbilicus, occupying space (vertically two or 
three inches) according to its distension. Behind 
and below the umbilicus, supposing the bladder 
contracted, are the small intestines, covered by the 
great omentum. 

64. Peritoneum. — The peritoneum is in con- 
tact with the linea alba all the way down to the 
pubes, when the bladder is empty. But when 
the bladder distends, it raises the peritoneum 
from the middle line above the pubes ; so that 
with a bladder distended half-way up to the 
umbilicus, there is a space of nearly two inches 
above the symphysis where the bladder may be 
tapped without risk of injury to the peritoneum. 
For the same reason, we have space sufficient for 
the successful performance of the high operation 
for stone. This fact in anatomy must have been 
well understood by Jean de Dot, the smith at 
Amsterdam, who, in the seventeenth century, cut 
himself in the linea alba above the pubes, and 
took out of his bladder a stone as large as a hen's 
egg. The stone, the knife, and the portrait of the 
operator, may be seen to this day in the museum 
at Leyden. 



THE ABDOMEN. 1 71 

65. Division of Aorta.— The aorta generally 
divides at a point one inch and a half below the 
umbilicus. A more reliable guide to this division 
than the umbilicus, is a point (a very little to the 
left) of the middle line about the level of the 
highest part of the crest of the ilium. A line 
drawn with a slight curve outwards from this 
point to the groin, where the pulsation of the 
common femoral can be distinctly felt (rather 
nearer to the pubes than the ilium), gives the 
direction of the common iliac and external iliac 
arteries. About the first two inches of this line 
belong to the common iliac, the remainder to the 
external. Slight pressure readily detects the pulsa- 
tion of the external iliac above " Poupart's liga- 
ment." 

As a rule, the length of the common iliac is 
about two inches, but it should be remembered 
there are frequent deviations. It may be between 
three-quarters of an inch and three inches and a 
half long. These varieties may arise either from 
a high division of the aorta, or a low division of 
the common iliac, or both. It is impossible to 
ascertain during life what is its length in a given 
instance, for there is no necessary relation between 
its length and the height of the stature. It is 
often short in tall men, and vice versa. Anatomists 
generally describe the right as a trifle longer than 



72 THE ABDOMEN. 

the left ; but their average length is pretty nearly 
the same. 

66. Mr. Abernethy, who in the year 1796 first 
put a ligature round the external iliac, made his 
incision in the line of the artery. But the easiest 
and safest way to reach the vessel is by an inci- 
sion (recommended in the first instance by Sir 
Astley Cooper, and now generally adopted) be- 
ginning just on the inner side of the artery, a 
little above Poupart's ligament, and continued 
upwards and outwards a little beyond the spine 
of the ilium. The same incision extended farther 
in the same direction would reach the common 
iliac. 

67. Bony Prominences. — The anterior supe- 
rior spine of the ilium, the spine of the pubes, 
and the line of Poupart's ligament, are landmarks 
with which every surgeon should be thoroughly 
familiar. 

68. Spine of Ilium. — The spine of the ilium 
is the spot from which we measure the length of 
the lower extremity. It is a valuable landmark 
in determining the nature of injuries to the pelvis 
and the hip. The thumb easily feels the spine, 
even in fat persons. Its position with regard to 
the trochanter major should be carefully exam- 
ined. The best way to do this is to place the 
thumbs firmly on the opposite spines, and to grasp 



THE ABDOMEN. 73 

the trochanters with the fingers. Any abnormal 
position on one side is thus easily ascertained with 
the sound side as a guide. 

[In all such measurements it is of the utmost 
importance that a line joining the two spines 
should be at right angles to the axis of the body, 
or the measurements cannot fail to be inaccurate. 
The spines also are so open to error, as points 
of measurement (for we scarcely ever * can get 
precisely corresponding points on the two sides), 
that I have long since adopted the following 
method. See that the body is straight and the 
pelvis (t. e., the line between the two spines) at 
right angles to it. Let an assistant hold the head 
immovably in the middle line. Let the patient 
seize the tape-line with his teeth. Measure one 
side, say to the inner malleolus. Then measure 
the other side, never by keeping the measure of 
the first side and simply passing across to the 
other leg, but by an independent measurement. 
The last precaution eliminates our pre-conceptions. 
The chief source of error here — which exists in 
all methods of measurement — is the position of 
the pelvis. The advantage is in one and the same 
starting-point, and that in the median line. 

It must not be forgotten, however, that there is 
not infrequently a normal difference in the length 
of the two legs.] 
7 



74 THE ABDOMEN. 

69. Spine of Pubes. — The spine of the pubes 
is the best guide to the external abdominal riDg. 
It cannot easily be felt by placing the finger 
directly over it, since it is generally covered by 
fat. To feel it distinctly, we should push up the 
skin of the scrotum and get beneath the subcu- 
taneous fat. If there be any difficulty in finding 
it, abduct the thigh, and the tense tendon of the 
adductor longus will lead up to it. 

The position of the spine of the pubes is ap- 
pealed to as a means of diagnosis in doubt between 
inguinal and femoral hernia. The spine lies on 
the outer side of the neck of an inguinal hernia, 
on the inner side of the neck of a femoral. 

The spine of the pubes is nearly on the same 
horizontal line as the upper part of the trochanter 
major. In this line, about one full inch external 
to the spine, is the femoral ring. Here is the seat 
of stricture in a femoral hernia. 

70. Poupart's Ligament, or Crural Arch. — 
The line of Poupart's ligament (crural arch) is in 
most persons indicated by a slight crescent-like 
furrow along the skin. It corresponds with a 
line drawn not straight, but with a gentle curve 
downwards from the spine of the ilium to the 
spine of the pubes. With the help of the preced- 
ing landmarks it is easy to find the exact position 



THE ABDOMEN. < D 

of the external and internal abdominal rings, and 
the direction of the inguinal canal. 

[In hernia, it is always treacherous to trust 
the eye. We must define exactly the iliac and 
pubic spines by the fingers, and draw the line of 
Poupart's ligament between them. It lies at the 
uppermost border of the "groin," or groove be- 
tween the abdomen and the thigh; and unless we 
so define its two ends we are very apt to get it, 
and especially the inner and most important end, 
too low, and so mistake the variety of hernia we 
have to deal with. 

Moreover, an examination of the external abdo- 
minal ring will disclose its condition and show 
whether the hernia is, or is not, inguinal. Un- 
fortunately, in women, in whom femoral hernia 
is most frequent, this examination is least satisfac- 
tory;. The exact location of the line of Poupart's 
ligament is, therefore, in women doubly important.] 

71. Abdominal Rings. — The external abdomi- 
nal ring is situated immediately above the spine 
of the pubes. It is an oval opening with the long 
axis directed obliquely downwards and inwards. 
Though its size varies a little in different persons, 
yet as a rule it will admit the end of the little 
finger, so that Ave can tell by examination whether 
it be free or otherwise. To ascertain this, the best 
way is to push up the thin skin of the scrotum 



76 THE ABDOMEN". 

before the finger ; then, by tracking the spermatic 
cord, the finger readily glides over the crest of the 
pubes and feels the sharp margins of the ring. 

The position of the internal ring is about 
midway between the spine of the ilium and the 
symphysis of the pubes, and about two-thirds of 
an inch above Poupart's ligament. 

72. Inguinal Canal. — The position of the exter- 
nal and internal abdominal rings being ascertained, 
it is plain that the direction of the inguinal canal 
must be obliquely downwards and inwards, and 
that its length in a well-formed adult male is from 
one and a half to two inches, according as we in- 
clude the openings or not. In very young children 
the canal is much shorter and less oblique, the 
inner ring being behind the outer. With the 
growth of the pelvis in its transverse direction, the 
anterior spines of the ilia become farther apart, and 
thus draw the internal ring more and more away 
from (z. e., to the outer side of) the external. 

73. Spermatic Cord. — The spermatic cord can 
be felt as it emerges through the external ring, 
and its course can be tracked into the scrotum. 
The vas deferens can be distinctly felt at the back 
of the cord, and separated from its other compo- 
nent parts. 

74. Epigastric Artery. — The direction of the 
deep epigastric artery corresponds with a line 



THE ABDOMEN. 77 

drawn from the inner border of the internal ringr 

o 

np the middle of the rectus muscle towards the 
chest. [It lies to the inside of oblique, and to the 
outside of direct inguinal hernia.] 

In thin persons the absorbent glands which lie 
along Poupart's ligament can be distinctly felt. 
They are usually oval, with their long axes 
parallel to the line of the ligament. 

75. Abdominal Viscera. — Now let us see how 
far we can make out externally the position and 
size of the abdominal viscera. 

To make this examination with anything like 
success, it is desirable to relax the abdominal 
muscles. The man should be on his back, the 
head, shoulders, and thorax being well raised, to 
relax the recti muscles ; and the thighs bent on 
the abdomen, to relax the several fasciae attached 
to the crural arch. To induce complete relaxa- 
tion, where a very careful examination is desired 
[ether or] chloroform should be given. 

In manipulating the abdomen we should not use 
the tips of the fingers. This is sure to excite the 
contraction of the muscles. The flat hand should 
be gently pressed upon it, and with an undulating 
movement. 

76. It is well to bear in mind that the central 
tendon of the diaphragm is about the level of the 
lower end o| the- sternum at its junction with the 

7* 



78 THE ABDOMEN. 

seventh costal cartilage ; that the right half of the 
diaphragm rises to about the level of the fifth rib — 
that is, about an inch below the nipple ; that the 
left half does not rise quite so high. In tranquil 
breathing the diaphragm descends about half an 
inch. 

The position of the abdominal viscera varies, to 
a certain extent, in different persons. In some of 
them, especially the stomach, their position varies 
in the same person at different times. 

Let us take, first, the largest of the abdominal 
viscera — the liver. 

77. Liver. — The liver lies under the right hypo- 
chondrium, and passes across the middle line over 
the stomach into the left hypochondrium, gene- 
rally speaking, as far as the left mammary line. 
The extent to which it can be felt below the 
edges of the ribs depends upon whether it is 
enlarged or not, as well as upon its texture, and 
also upon the amount of flatus in the stomach 
and intestines. As a rule, in health its lower thin 
border projects about half an inch below the costal 
cartilages, and can be felt moving up and down 
with the action of the diaphragm ; but it requires 
an educated hand to feel it. An uneducated hand 
would miss it altogether. That part of it, how- 
ever, which crosses the middle line below the 
ensiform cartilage is much more accessible to the 



THE ABDOMEN. 79 

feel ; here it lies immediately behind the linea 
alba, and in front of the stomach, nearly half way 
down to the umbilicus. Here, therefore, is the 
best place to feel whether the liver be enlarged or 
pushed down lower than it ought to be. If it be 
much enlarged and much lower, even the most 
untutored hand could detect its edge. 

Even if the edge of the liver be felt very much 
lower than its normal below the ribs, it does not 
necessarily follow that the liver is enlarged, since 
it may be pressed down by other causes — for 
instance, the habit of wearing tight stays. 

To what height does the liver ascend? This 
can only be ascertained by careful percussion of 
the chest wall. The highest part of its convexity 
on the right side is about one inch below the 
nipple, or nearly on a level with the external and 
inferior angle of the pectoralis major. Posteriorly 
the liver comes to the surface below the base of 
the right lung, above the level of the tenth dorsal 
spine. 

Eoughly speaking, the upper border of the liver 
corresponds with the level of the tendinous centre 
of the diaphragm ; that is, the level of the lower 
end of the sternum. Thus a needle thrust into 
the right side, between the sixth and seventh ribs, 
would traverse the lung, and then go through the 
diaphragm into the liver. 



80 THE ABDOMEN. 

78. Gall Bladder.— The gall bladder, or rather 
the fundus of it, is situated, but cannot be felt, 
just below the edge of the liver about the ninth 
costal cartilage, outside the edge of the right 
rectus muscle. 

79. Stomach. — The stomach varies in size more 
than any [other] organ in the body. When empty 
and contracted (63) it lies at the back of the 
abdomen, overlapped by the left lobe of the liver, 
and in front of the pancreas. When very full, it 
turns on its axis and swells up towards the front, 
coming close behind the wall of the abdomen, 
occupying most of the left hypochondrium and epi- 
gastrium, displacing the other contiguous organs, 
pushing in every direction, and often interfering 
with the action of the heart and left lung. Hence 
the palpitation and distressing heart-symptoms in 
indigestion and flatulence. 

The cardiac orifice of the stomach lies to the 
left of the middle line, just below the level of the 
junction of the seventh costal cartilage with the 
sternum. 

80. Pylorus. — The pylorus lies under the liver, 
on the right side, near the end of the cartilage of 
the eighth rib; but it cannot be felt unless occa- 
sionally when enlarged and hardened by disease. 

81. Spleen. — The spleen, if it be healthy, can- 
not be felt, so completely is it sheltered by the 



THE ABDOMEN. 81 

ribs. It lies on the left side, connected to the 
great end of the stomach,- beneath the ninth, tenth, 
and eleventh ribs, between the axillary lines — lines 
drawn vertically downwards from the anterior and 
posterior margins of the axilla. Its upper edge 
is on a level with the spine of the ninth dorsal 
vertebra, its lower with the spine of the eleventh. 

Its position and size, therefore, in health can 
only be ascertained, and not very accurately, by 
the extent of dulness on percussion. The greatest 
amount of dulness would be over the tenth and 
eleventh ribs ; above this the thin edge of the 
lung would intervene between the spleen and the 
abdominal wall. If, therefore, the spleen can be 
distinctly felt below the ribs, it must be enlarged. 
In proportion to its enlargement, so can its lower 
rounded border be detected below the tenth and 
eleventh ribs, especially when forced downwards 
by a deep inspiration. 1 

82. Pancreas. — The pancreas lies transversely 
behind the stomach, and crosses the aorta and the 
spine about the junction of the first and second 
lumbar vertebrae. The proper place to feel for it, 
therefore, would be in the linea alba about two or 
three inches above the umbilicus. Is it percepti- 

1 See some good observations on the position of the enlarged 
spleen, by Sir W. Jenner, "Brit. Med. Journ.," Jan. 16, 1869. 



82 THE ABDOMEN. 

ble to the touch ? — only under very deep pressure, 
and very favorable circumstances, such as an 
emaciated and empty abdomen. It is worth 
remembering that it may be felt under such con- 
ditions. The pancreas of normal size, in thin 
persons, has been mistaken for disease — disease of 
the transverse arch of the colon, or aneurism of 
the abdominal aorta. 

83. Kidney. — The kidney lies at the back of 
the abdomen, on the quadratus lumborum and 
psoas muscles, opposite the two lower dorsal and 
two upper lumbar spines. The right, owing to 
the size of the liver, is a trifle — say, three-quarters 
of an inch — lower than the left. The pelvis of the 
kidney is on about the level of the spine of the 
first lumbar vertebra: the upper border is on 
about the level of the space between the eleventh 
and twelfth dorsal spines ; the lower border comes 
as low as the third lumbar spine. During a deep 
inspiration both kidneys are depressed by the 
diaphragm nearly half an inch. 

Can we feel the normal kidney? The only 
place where it is accessible to pressure is just 
below the last rib, on the outer edge of the 
"erector spinae." I say accessible to pressure, for 
I have never succeeded in satisfying myself that 
I have distinctly felt its rounded lower border 
in the living subject, nor even in the dead, with 



THE ABDOMEN". 83 

the advantage of flaccid abdominal walls and the 
opportunity of making hard pressure with both 
hands, placed simultaneously, one in front of the 
abdomen, the other on the back. For these reasons, 
although we can easily ascertain its degree of 
tenderness, we cannot actually feel it -unless it be 
considerably enlarged. 

We must be on our guard not to mistake for 
the kidney an enlarged liver or spleen, or an 
accumulation of feces in the lumbar part of the 
colon. [As Sir William Jenner has pointed out, 
the anterior border of the spleen is sharp, and 
may be notched, in both of which respects it differs 
from the kidney, even when enlarged.] 

84. Large Intestine. — Let us now trace the 
large intestine and see where it is accessible to 
pressure. The "caecum," or "caput coli," and the 
ileo-caacal valve lie in the right iliac fossa. The 
ascending colon runs up the right lumbar region 
over the right kidney. [For its line, see § 51.] 
The transverse colon crosses the abdomen two or 
three inches above the umbilicus. The descending 
colon lies in the left lumbar region in front of the 
left kidney. The sigmoid flexure occupies the left 
iliac fossa. 

Throughout this tortuous course, except at the 
hepatic and splenic flexures, the colon is accessible 
to pressure, and we could, under favorable circum- 



84: THE ABDOMEN. 

stances, detect hardened feces in it. In a case 
which occurred in St. Bartholomew's Hospital, a 
collection of feces in the transverse colon formed a 
distinct tumor in the abdomen. All the symptoms 
yielded to large and repeated injections of olive 
oil. In another- case an accumulation of fecal 
matter in the sigmoid flexure during life was 
mistaken for a malignant disease. 

85. Colotomy. — The operation of opening the 
colon (colotomy) may be done in the right or left 
loin, below the kidney, in that part of the colon 
not covered by peritoneum. 

The landmarks of the operation are: — (1) The 
last rib, of which feel the sloping edge; (2) the 
crest of the ilium ; (3) the outer border of the 
"erector spinas." The incision should be about 
three inches long, midway between the rib and 
the ilium. It should begin at the outer border of 
the "erector spinas," and should slope downwards 
and outwards in the direction of the rib. The 
edge of the "quadratus lumborum," which is the 
guide to the colon, is about one inch external to 
the edge of the "erector spinas," or three full 
inches from the lumbar spines. The line of the 
gut is vertical, and runs for a good two inches 
between the lower border of the kidney and the 
iliac crest on the left side; rather less on the 
right. 



THE ABDOMEN. 85 

Small Intestines. — All the room below the 
umbilicus is occupied by the small intestines. 
The coils of the jejunum lie nearer to the umbili- 
cus (one reason of the great fatality of umbilical 
hernias). Those of the ilium are lower down. [As 
the patches of Peyer involved in typhoid fever lie 
chiefly near the lower end of the ilium, which 
terminates at the ilio-cascal valve, this will account 
for the tenderness found here. 

It must be remembered that in ascites, while 
the fluid will gravitate to the lowest point in the 
abdominal cavity, the intestines, being filled with 
air and tethered to the spine by the mesentery, 
will float on top. Hence the value of " postural 
diagnosis," i. e., percussion in different postures, on 
the right side, the left side, the back, etc. In any 
solid or encysted tumor this cannot hold good.] 

On the right side, a little below the ninth rib, 
the colon lies close to the gall bladder, and is, 
after death, sometimes tinged with bile. Pos- 
teriorly, this part of the colon is in contact with 
the kidney and duodenum. 

86. Bladder. — When the bladder distends, it 
gradually rises out of the pelvis into the abdomen, 
pushes the small intestines out of the way [lifts 
the peritoneum off from its anterior wall], and 
forms a swelling above the pubes, reaching in 
some instances up to the navel. The outline of 
8 



Ob THE PERINEUM. 

this swelling is perceptible to the hand as well as 
to percussion. More than this, fluctuation can be 
felt through the distended bladder by tapping on 
it in front with the fingers of one hand, while the 
forefinger of the other passed up the rectum feels 
the bottom of the "trigone." 

THE PERINEUM. 

The body is supposed to be placed in the usual 
position for lithotomy. 

87. Bony Framework. — We can readily feel 
the osseous and ligamentous boundaries of the 
perineum ; namely, the rami of the pubes and 
ischia, the tuberosities of the ischia, the great 
sacro-ischiatic ligaments, and the apex of the 
coccyx. This framework forms a lozenge-shaped 
space. If we draw an imaginary line across it 
from the front of one tuber ischii to the other, we 
divide this space into an anterior and a posterior 
triangle. The anterior is nearly equilateral, and, 
in a well-formed pelvis, its sides are from three 
to three and a half inches long. It is called the 
urethral triangle. The posterior, containing the 
greater part of the anus and the ischio-rectal fossa 
on each side, is called the anal triangle. 

88. Raphe. — A slight central ridge of skin, 
called the " raphe," runs from the anus up the 



THE PERINEUM. 87 

perineum, scrotum, and penis. This "raphe," or 
middle line of the perineum, is the "line of safety" 
in making incisions to let out matter or effused 
urine, or to divide a stricture. 

89. Central point of Perineum. — It is very 
important to know that a point of the raphe 
about midway between the scrotum (where it 
joins the perineum) and the centre of the anus, 
corresponds with the so-called "central tendon" 
where the perineal muscles meet. The bulb of 
the urethra lies above this point, and never, at 
any age, comes lower down. The artery of the 
bulb, too, never runs below this level. Therefore 
the incision in lithotomy should never commence 
above it. A knife introduced at this point, and 
pushed backwards with a very slight inclination 
upwards, would enter the membranous part of 
the urethra just in front of the prostate gland; 
pushed still farther it would enter the neck of 
the bladder. This point, then, is a very good 
landmark to the urethra in lithotomy, or, indeed, 
in any operations on the perineum. 

The incision in the lateral operation of litho- 
tomy, beginning below the point indicated, should 
be carried downwards and outwards between the 
anus and the tuberosity of the ischium, a little 
nearer to the tuberosity than the anus [because 
the rectum is wider than the anus]. The lower 



85 THE PERINEUM. 

end of the incision should reach a point just below 
the [level of the] anus. 

90. Triangular Ligament. — In a thin peri- 
neum, we can feel the lower border of the deep 
perineal fascia or the "so-called" triangular liga- 
ment of the urethra. The urethra passes through 
it about one inch below the lower part of the sym- 
physis pubis, and about three-quarters of an inch 
higher than the central tendon of the perineum. 
It is important to bear in mind these landmarks 
in introducing a catheter. If the catheter be 
depressed too soon, its passage will be resisted by 
the triangular ligament ; if too late, it will be 
likely to make a false passage by running through 
the bulb. 

91. Anus. — One of the most important land- 
marks which guide a surgeon in his operation 
about the anus, is a white line 1 at the junction 
of the skin and mucous membrane. It is easily 
recognized and is of especial interest, because it 
marks with great precision the linear interval 
between the external and internal sphincter mus- 
cles. From this line the internal sphincter extends 
upwards, beneath the mucous membrane, for about 
an inch, becoming gradually more and more at- 
tenuated. 

1 "Lectures on Rest and Pain," by John Hilton, F.R S. 
London, 18G3, p. 280. 



THE PERINEUM. ©9 

The wrinkled appearance of the anus is caused 
by the contraction of the external sphincter. At 
the bottom of these cutaneous folds, especially 
towards the coccyx, we look for "fissure of the 
anus." 

92. Landmarks in the Rectum. — Many valu- 
able landmarks may be felt by introducing the 
finger into the rectum, with a catheter at the 
same time in the urethra. The principal of these 
landmarks are the following : — 

a. The finger can feel the extent and powerful 
grasp of the internal sphincter for about one inch 
up the bowel. (91) 

h. Urethra. — Through the front wall of the 
bowel it can most distinctly feel the track of the 
membranous part of the urethra, exactly in the 
middle line. This is very important, because you 
can ascertain with precision whether the catheter 
has deviated from the proper track. 

c Prostate Gland. — About an inch and a half 
or two inches from the anus, the finger comes 
upon the prostate gland. The gland lies in close 
contact with the bowel, and can be detected by its 
shape and hard feel. The finger, moved from side 
to side, can examine the size of its lateral lobes, 
their consistence and sensibility. 

d. The finger, introduced still farther, can reach 
beyond the prostate, as far as the apex of the tri- 



90 THE PERINEUM. 

gone of the bladder. More than this, it can feel 
the angle between the ' ( ductus communes ejacu- 
latorii," which forms the apex of the trigone. 
This is the precise spot where the distended 
bladder should be punctured through the rectum. 
The more distended the bladder, the easier can 
this spot be felt. Fluctuation is at once detected 
by a gentle tap on the bladder above the pubes 
(86). The trocar must be thrust in the direction 
of the axis of the distended bladder; that is, 
roughly speaking, in a line drawn from the anus 
through the pelvis to 'the umbilicus. 

e. The fold of peritoneum, called the recto- vesi- 
cal pouch, is about four inches from the anus, 
therefore it is not within reach of the finger ; and 
we run no risk of wounding it in tapping the 
bladder if the trocar be introduced near the 
angle of the trigone. [Roberts has measured the 
distance of the recto- vesical (or recto- vaginal) 
pouch from the anus, both in situ and after 
removal from the body. The distance was one 
and a quarter to two inches in situ, and from 
three and a half to four and a quarter inches after 
removal.] 

/. The finger can feel one of the ridges or folds 
of mucous membrane which are situated at the 
lower part of the rectum. This fold projects from 
the side, and sometimes from the upper part of the 



THE PERINEUM. 91 

rectum, near the prostate. When thickened or 
ulcerated, this fold occasions great pain in defeca- 
tion ; and great relief is afforded by its division. 

g. Lastly, the finger can examine the condition 
of the spaces filled with fat on either side of the 
rectum, called the ischio-rectal fossae, with a view 
to ascertain the existence of deep-seated collections 
of matter, or the internal communications of 
fistulas. 

[It is often important to instruct mothers and 
nurses as to the difference in the direction of the 
anus and that of the rectum, in order that they 
may introduce the nozzle of an enema syringe 
without pain. The rectum, after following the 
curve of the sacrum and coccyx, suddenly bends 
backward and terminates in the anus. The axis 
of the anal opening is in the direction of the 
navel for about an inch, and when the finger, the 
syringe-nozzle, or other instrument, has been intro- 
duced thus far, it may then be swept around so as 
to point to the small of the back and be pushed 
in as far as necessary. 

It is useful to remember that in women the 
posterior wall of the vagina can be everted from 
the rectum, and, vice versa, the rectum from the 
vagina, and so be carefully examined without a 
speculum.] 



92 THE PERINEUM. 

Introduction of Catheters.— In the introduc- 
tion of catheters the following are good rules. 
Keep the point of the instrument well applied 
against the upper surface of the urethra; — depress 
the handle at the right moment (90) ; — keep the 
umbilicus in view ; — in cases of difficulty feel the 
urethra through the rectum, to ascertain whether 
the instrument be in the right direction. Atten- 
tion to these rules diminishes the risk of making 
a false passage, an injury which under great deli- 
cacy in manipulation ought never to happen. 

Urethra in the Child. — In children the mem- 
branous part of the urethra is, relatively speaking, 
very long, owing to the smallness of the prostate. 
It is also more sharply curved, because the bladder 
in children is more in the abdomen than in the 
pelvis. It is, moreover, composed of thin and 
delicate walls. The greatest gentleness, therefore, 
should be used in passing a catheter ; else the 
instrument is likely to pass through the coats 
and make a false passage. Hence the advantage 
of being able to ascertain through the rectum 
whether the instrument be in the right track and 
moving freely in the bladder, which can also be 
easily felt in children. 



THE THIGH. 93 

THE THIGH. 

93. Poupart's Ligament, or Crural Arch.— 

Mark the anterior superior spine of the ilium, the 
spine of the pubes, and define the line of "Pou- 
part's ligament" which extends between them. 
This line is one of our guides in the diagnosis of 
inguinal and femoral hernias. If the bulk of the 
tumor be above the line, the hernia is probably 
inguinal ; if below it, femoral. The line is not a 
straight one drawn from the spine of the ilium to 
the spine of the pubes, but slightly curved, with 
the convexity downwards, owing to its close con- 
nection with the fascia lata of the thigh. In many 
persons it can be distinctly felt ; in nearly all its 
precise course is indicated by a slight furrow in 
the skin. 

For the points about the spine of the pubes, 
refer to paragraph 69. 

91. Furrow at the Bend of the Thigh.— 
When the thigh is even slightly bent, there 
appears a second furrow in the skin below that 
at the crural arch. This second furrow begins at 
the angle between the scrotum and the thigh, 
passes outwards, and is gradually lost between the 
top of the trochanter and the anterior superior 
spine of the ilium. It runs right across the front 
of the capsule of the hip-joint. For this reason it 



94 THE THIGH. 

is a valuable landmark in amputation at the hip- 
joint. The point of the knife should be introduced 
externally where the furrow begins, should run 
precisely along the line of it, and come out where 
it ends ; so that the capsule of the joint may be 
opened with the first thrust. In suspected disease 
of the hip, pressure made in this line, just below 
the spine of the ilium, will tell us if the joint be 
tender. Effusion into the joint obliterates all 
trace of the furrow, and makes a fulness when 
contrasted with the opposite groin. 

95. Saphenous Opening. — In most persons 
there is a natural depression over the saphenous 
opening in the fascia lata, where the saphena vein 
joins the femoral. The position of this opening is 
just below the inner third of Poupart's ligament, 
and about an inch and a half external to the spine 
of the pubes. This is the place where the swell- 
ing of a femoral hernia first appears : therefore it 
ought to be carefully examined in cases of doubt. 

96. Femoral Ring. — The position of the fe- 
moral ring, through which the hernia escapes 
from the abdomen, is, on a deeper plane, about 
half an inch higher than the saphenous opening, 
and immediately under Poupart's ligament. As 
the plane of the ring is vertical in the supine 
position of the body, the way in which we should 
try to reduce a femoral hernia is by pressure, 



THE THIGH. 95 

applied first in a downward direction, afterwards 
in an upward. The intestine protruded has to 
pass back under a sharp edge of fascia, namely, 
the upper horn of the saphenous opening (known 
as Hey's ligament). At the same time we bend the 
thigh, to relax the fascia as much as possible. 

A good way to find the seat of the femoral ring 
with precision is the following: — Feel for the pul- 
sation of the femoral artery on the pubes ; allow 
half an inch (on the inner side) for the femoral 
vein ; then comes the femoral ring. 

In performing the operation for the relief of the 
stricture in femoral, hernia the incision through 
the skin should be about an inch and a half ex- 
ternal to the spine of the pubes. Its direction 
should be vertical, and its middle should be just 
over the femoral ring. 

97. Lymphatic Glands in the Groin.— The 
cluster of inguinal and femoral lymphatic glands 
can sometimes be felt in thin persons. The ingui- 
nal lie for the most part along the line of Pou- 
part's ligament : they receive the absorbents from 
the wall of the abdomen, the urethra, the penis, 
the scrotum [perineum, gluteal region], and the 
anus. The femoral glands lie chiefly over the 
saphenous opening and along the outer side of 
the saphena vein : they receive the absorbents 
of the lower extremity ; they receive some- also 



96 THE THIGH. 

from the scrotum — of which we have practical 
evidence in cases of chimney-sweepers' cancer. 

98. Trochanter Major. — The trochanter major 
is a most valuable landmark, to which we are 
continually appealing in injuries and diseases of 
the lower extremity. There is a natural depres- 
sion over the hip (in fat persons) where it lies very 
near the surface, and can be plainly felt, especially 
when the thigh is rotated. Nothing intervenes 
between the bone and the skin except the strong 
fascia of the gluteus maxim us and the great bursa 
underneath it. 

The top of the trochanter lies pretty nearly on 
a level with the spine of the -pubes, and is about 
three-fourths of an inch lower than the top of the 
head of the femur. A careful examination of the 
bearing of the great trochanter to the other bony 
prominences of the pelvis, and a comparison of its 
relative position with that of the opposite side, 
are the best guides in the diagnosis of injuries 
about the hip, and the position of the head of the 
femur. 

99. Nelaton's Line. — "If in the normal state 
you examine the relations of the great trochanter 
to the other bony prominences of the pelvis, you 
will find that the top of the trochanter corresponds 
to a line drawn from the anterior superior spine 
of the ilium to the most prominent part of the 



THE THIGH. 97 

tuberosity of the ischium. This line also runs 
through the centre of the acetabulum. The extent 
of displacement in dislocation or fracture is marked 
by the projection of the trochanter behind and 
above this line." 1 

"Ne*laton's line," as it is termed, theoretically 
holds good. But in stout persons it is not always 
easy to feel these hony points so as to draw the 
line with precision. A surgeon must, after all, in 
many cases trust to measurement by his eyes and 
his flat hands — his best guides. Thus, let the 
thumbs be placed firmly on the spines of the ilia, 
while the fingers grasp the trochanters on each 
side. Having- the sound side as a standard of 

o 

comparison, the hand will easily detect any dis- 
placement on the injured side. Hippocrates bids 
us compare the sound parts with the parts affected 
(in fractures) and observe the inequalities. 

The top of the great trochanter is the guide in 
an operation recently introduced by Mr. Adams, 
namely, the "subcutaneous section of the neck of 
the femur." "The puncture should be made one 
inch above and nearly one inch in front of the top 
of the trochanter. The neck of the bone is to be 
sawn through at right angles to its axis, the saw 

1 Nelaton, " Patholoorie chirurgicale," t. iv. p. 441. 1848. 
9 



98 THE THIGH. 

working parallel to Poupart's ligament, and about 
one inch below it." 

Spine of the Ilium. — The anterior superior 
spine of the ilium is the point from which we 
measure the length of the lower limb. [See § 68.] 
By looking at the spines of opposite sides we can 
detect any slant in the pelvis. By pressure on 
both spines simultaneously we examine if there 
be a fracture of the pelvis, or disease at the sacro- 
iliac joint. 

100. "In reducing a dislocation of the hip by 
manipulation it is important to bear in mind that, 
in every position, the head of the femur faces 
nearly in the direction of the inner aspect of its 
internal condyle." 1 

101. Compression of Femoral Artery. — 
About a point midway between the spine of the 
ilium and the symphysis pubis, the femoral artery 
can be felt beating, and effectually compressed, 
against the pubes. How should the pressure be 
applied when the patient lies on the back? In 
accordance with the slope of the bone — that is, 
with a slight inclination upwards. A want ot 
attention to this point is the reason why so many 
fail when they undertake to command the circula- 

1 Bigelow, ' ' Mechanism of Dislocation and Fracture of the 
Hip." Philadelphia, 1869. 



THE THIGH. 99 

tion through the femoral artery in an amputation, 
or to cure an aneurism by digital compression. [I 
think the chief reason of failure in attempting 
compression of the femoral is that pressure is 
made two or three inches below Poupart's liga- 
ment, instead of immediately below it. In the 
former position, thick muscles form the floor 
against which it is ineffectually compressed ; in 
the latter, it is directly on the edge of the pelvis 
or the head of the femur.] 

If the Italian tourniquet be used, we should be 
careful to adjust the counter-pad well under the 
tuberosity of the ischium. If digital pressure be 
used, it is easy to command the femoral by slight 
pressure of the thumb, provided the fingers have 
a firm hold on the great trochanter. 

102. Sartorius. — The sartorius is the great 
fleshy landmark of the thigh, as the biceps is of 
the arm, and the sterno-cleido-mastoideus of the 
neck. Its direction and borders may easily be 
traced by asking the patient to raise his leg, a 
movement which puts the muscle in action. The 
same action defines the boundaries of the triangle 
(of Scarpa) formed b}^ Poupart's ligament, the 
adductor longus and sartorius. 

Line of Femoral Artery. — To define the 
course of the femoral artery, draw a line from 
midway between the anterior superior spine of 



100 THE THIGH. 

the ilium and the symphysis pubis to the (spur- 
like) tubercle for the adductor magnus on the 
inner side of the knee. The femoral artery lies 
under the upper § of this line. 

The sartorius begins to cross the artery, as. a 
rule, from three to four inches below Poupart's 
ligament. The point at which the profunda artery 
arises is about one and a half or two inches below 
the ligament. Therefore the incision for trying 
the femoral in Scarpa's triangle should commence 
about a hand's breadth below Poupart's ligament, 
and be continued for three inches in the line of the 
artery. 

To command the femoral in Scarpa's triangle, 
the pad of the tourniquet should be placed at the 
apex, and the direction of the pressure should be, 
not backwards, but outwards, so that the artery 
may be compressed against the femur. 

In the middle third of the thigh the femoral 
artery lies in Hunter's canal, overlapped by the 
sartorius. About the commencement of the lower 
third the artery leaves the canal through the oval 
opening in the adductor magnus, and, under the 
name of popliteal, enters the popliteal space. The 
line for finding the artery in Hunter's canal has 
been already traced (102). The incision to reach 
the artery in this part of its course would fall in 
with the outer border of the sartorius. 



THE BUTTOCKS. 101 

To command the femoral artery in Hunter's 
canal, the pressure should be directed outwardly, 
so as to press the vessel against the bone. 

THE BUTTOCKS. 

103. Buttocks. — Bony Landmarks. — The 

bony landmarks of the buttocks which can be 
distinctly felt are : 1, the posterior superior spine 
of the ilia ; 2, the spines of the sacral vertebras ; 
3, the two tubercles of the last sacral vertebra ; 4, 
the apex of the coccyx in the deep groove leading 
to the anus ; 5, the tuberosities of the ischia on 
each side of the anus. 

The posterior spines of the ilia are about the 
level of the second sacral spine, and corresponds 
with the middle of the sacro-iliac symphysis. 

The third sacral spine marks the lowest level 
to which the membranes of the cord and the 
cerebro-spinal fluid descend in the spinal canal. 

The tuberosities of the ischia, in the erect posi- 
tion, are covered by the gluteus maximus. In the 
sitting position they support the weight of the 
body, and are only covered by a thick pad of 
coarse fat. Between this pad and the bones there 
is a bursa, which becomes occasionally enlarged 
and inflamed in coachmen. 

The prominence of the nates is one of the 
9* 



102 THE BUTTOCKS. 

characteristics of man in connection with his erect 
attitude. " Les fesses n'appartiennent qu'a, l'espece 
humaine." They are formed of an accumulation 
of fat over the great muscle of the buttock (gluteus 
maximus). From their appearance we may gather 
some indication of the state of the constitution. 
They are firm and globose in the vigorous ; loose 
and flaccid in the infirm. Wasting and flattening 
of one, compared with the other, is an early symp- 
tom of disease in the hip. 

104. Fold of the Buttock.— The deep furrow, 
termed "the fold of the buttock" [or gluteo-femoral 
fold], which separates the nates from the back of 
the thigh, corresponds with the lower border of 
the gluteus maximus. Its altered direction in dis- 
ease of the hip is very characteristic. This is the 
best place to feel for the great ischiatic nerve. We 
find it by pressing deeply between the trochanter 
and the tuber ischii, rather nearer to the latter. 
When we sit upright, the nerve is not liable to 
pressure ; but it becomes numbed when we sit 
long sideways. 

105. Gluteal Artery. — To find at what point 
the gluteal artery comes out of the pelvis, draw a 
line from the posterior superior spine of the ilium 
to the top of the trochanter major, rotated inwards. 
The junction of the inner with the middle third of 
this line lies over the artery as it emerges from 
the upper border of the great ischiatic notch. 



THE KNEE. 103 

The point of exit of the ischiatic artery from 
the pelvis is about half an ioch lower than that of 
the gluteal. 

106. Pudic Artery. — The pudic artery crosses 
the spine of the ischium. To find it, draw a line 
from the outer side of the tuber ischii to the 
posterior superior spine of the ilium. The junc- 
tion of the lower with the middle third gives the 
position of the artery. The ischiatic artery lies 
close to it, but nearer the middle line. 

Looking at the course of these arteries it ap- 
pears that when we sit on hard seats the pressure 
is sustained by the bones ; when we recline on soft 
seats the pressure is sustained more by the soft 
parts, and reaches the arteries; hence the tendency 
of modern modes of reposing to drive the blood 
into the interior of the pelvis and favor the pro- 
duction of piles and uterine disorders. A cele- 
brated French accoucheur used to say that the 
fashion of high waists, tight lacing, and easy 
chairs brought him many thousands a year. 

THE KNEE. 

107. Bony Points. — The patella ; the tuberosi- 
ties of the two condyles; the tubercle of the tibia 
for the attachment of the ligamentum patellae ; 
another (the lateral) tubercle, on the outer side of 



104 THE KNEE. 

the head of the tibia ; and the head of the fibula 
are the chief bony landmarks of the knee. 

Observe that the head of the fibula lies at the 
outer and back part of the tibia, and that it is 
pretty nearly on a level with the tubercle for the 
attachment of the ligamentum patellae. 

We can also feel the adductor tubercle or spur- 
like projection of bone above the internal condyle 
which gives attachment to the tendon of the ad- 
ductor magnus. This spur-like projection corre- 
sponds with the level of the epiphysis of the 
lower end of the femur, and also with the level 
of the highest part of the trochlea for the patella: 
facts worth notice in performing excision of the 
knee. [The importance of preserving intact this 
inferior epiphysial cartilage of the femur is best 
understood when it is remembered that this is the 
seat of the greatest growth in the entire body. 
While the whole body from birth to adult life 
grows (in the male) 3.37 times, and the whole leg 
4.49 times, the lower femur grows 7.30 times.] 

" In reducing a dislocation of the hip, it is 
important to bear in mind that the inner aspect of 
the internal condyle in every position of the limb 
faces nearly in the direction of the head of the 
femur." (100) 

The tubercle on the outer side of the head of the 
tibia gives attachment to the broad and strong 



THE KNEE. 105 

aponeurosis (tendon of the tensor fasciae), which, 
acting like a brace for the support of the pelvis, 
is well seen in emaciated persons down the outer 
side of the thigh. [In fracture of the neck of the 
femur, therefore, instead of being tense, the fascia 
will yield to pressure, especially just above the 
knee and the great trochanter. The patient should 
be standing (Allis).] This tubercle indicates the 
level to which the condyles of the femur descend, 
and the lower level of the synovial membrane. 

The patella, in extension of the knee, is nearly 
all above the condyles ; in flexion, it lies in the 
inter-condyloid fossa (more on the external con- 
dyle), and thus protects the joint in kneeling. Its 
inner border is thicker and more prominent than 
the outer, which slopes down towards its con- 
dyle. 

108. Ligamentum Patellae. — The line of the 
ligamentum patella? is vertical. Hence any devia- 
tion from this line, one way or the other, indicates 
more or less dislocation of the tibia. There is a 
pellet of fat under the ligament, which answers a 
" packing" purpose — sinking in when the knee is 
bent; rising when the knee is extended, and bulg- 
ing on either side of the tendon, almost enough 
to give the feel of fluctuation. 

In a well-formed leg the ligamentum patellae, 
the tubercle of the tibia, and the middle of the 



106 THE KNEE. 

ankle should be in the same straight line. A 
useful point in the adjustment of fractures. 

Behind the upper half of the ligamentum patellae 
is the synovial membrane of the knee-joint; behind 
the lower half is a synovial bursa and a pad of fat. 
It is well to remember this in cases of injury to 
the ligamentum patellae. 

109. Patellar Bursa. — The patellar or house- 
maid's bursa is situated not only over the patella, 
but over the upper part of the ligament. This is 
plain enough when the bursa becomes enlarged. 
There is another subcutaneous bursa over the 
insertion of the ligament into the tubercle of the 
tibia. This is quite independent of the deep bursa 
between the tendon and the bone. 

110. Synovial Membrane of Knee. — The 
synovial membrane of the knee, when the joint is 
extended, rises like a cul-de-sac above the upper 
border of the patella about two inches. It ascends, 
too, a little higher under the vastus internus than 
the vastus externus — a fact very manifest when 
the joint is distended. When the knee is bent 
this cul-de-sac is drawn down — hence the rule of 
bending the knee in operations near the lower end 
of the femur. 

The lower level of the synovial membrane of 
the knee is just above the level of the upper part 
of the head of the fibula. The tibio-fibular syno- 



THE KNEE. 107 

vial membrane is, with rare exceptions, indepen- 
dent of that of the knee. 

[It is surprising to note what a large part of 
the surface of the joint, and especially on the 
femur, is exposed to examination by the touch 
with the knee in flexion. The condition of the 
synovial membrane and the cartilage, therefore, 
can be ascertained. The trochlear groove is espe- 
cially well defined.] 

111. Popliteal Tendons. — The tendons form- 
ing the boundaries of the popliteal space can be 
distinctly felt when the muscles which bend the 
knee are acting. On the outer side, we have the 
biceps running down to the head of the fibula. 
On the inner side we feel three tendons, disposed 
as follows: — nearest to the middle of the popliteal 
space is the semitendinosus, very salient and 
traceable high up the thigh ; next comes the 
thick round tendon of the semimembranosus ; still 
more internally is the gracilis. The sartorius, 
which forms a graceful muscular prominence on 
the inner side of the knee, does not become tendi- 
nous until it gets below it. 

[A very interesting experiment may be tried 
on the "ligamentous action" (as Prof. Cleland 
calls it) of these muscles. Standing with the back 
fixed against a wall to steady especially the pelvis, 
the knee can be made almost to touch the bellv. 



108 THE KNEE. 

But note that the knee is flexed. Repeat the 
experiment, the knee being kept rigid, and when 
the heel has been but slightly raised a sharp pain 
in the ham follows any effort to carry it higher. 
Flexion of the rigid leg from the vertical line to a 
right angle increases the distance from the tuber 
ischii to the tuberosities of the tibia by some six 
or eight centimetres, an amount of stretching these 
muscles cannot undergo. Hence the compulsory 
flexion of the knee in flexion of the hip. 

The same thing is seen in the wrist. Flex the 
wrist with the fingers extended, and again with 
the fingers in a "fist." The first movement can be 
carried to 90°, the second only to 30°, or in some 
up to 60°. Making a fist had already stretched 
the flexors, and they can be stretched but little 
further. Many surgeons make errors in the leg, 
but especially in the forearm and hand, and inflict 
injury as well as needless pain by forgetting these 
facts while making passive movement. 

It must be noted, however, that in children 
there is less danger of this over-stretching, for 
from childhood to old age there is a progressive 
invasion of the extensible belly by the inextensible 
tendon in the muscles generally. Hence the ease 
with which children, even when seated, can lift 
the heel (without moving the pelvis) and make 
the hips the point of an acute angle.] 



THE KNEE. 109 

112. Popliteal Bursa. — The precise position of 
this bursa in the popliteal space, which sometimes 
enlarges to the size of a hen's egg, is between the 
tendon of the inner head of the gastrocnemius and 
the tendon of the semimembranosus, just where 
they rub one against the other. The bursa is 
from one and a half to two inches long. When 
enlarged, it makes a swelling on the inner side of 
the popliteal space, which bulges and becomes 
tense when the knee is extended, and vice versa. 
I examined 150 bodies with a view to ascertain 
how often this bursa communicates with the syno- 
vial membrane of the knee. There was a commu- 
nication about once in five instances. This should 
make us cautious in interfering too roughly with 
the bursa when enlarged. 

113. Popliteal Artery. — The popliteal artery 
can be felt beating and can be compressed against 
the back of the femur, close to which it lies. But 
pressure, sufficient to stop the blood, should be 
firm, and should be made against the bone nearer 
to the inner than the outer hamstrings. The line 
of the artery corresponds with the middle of the 
ham. It lies under cover of the fleshy belly of 
the semimembranosus, and the outer border of 
this muscle is the guide to it. An incision down 
the middle of the ham would fall in with the 
vessel just above the condyles. 

10 



110 THE LEG AND ANKLE. 

114. Peroneal Nerve. — The peroneal nerve 
runs parallel with and close to the inner border 
of the tendon of the biceps. It can be felt in 
thin persons. There is a risk of dividing it in 
tenotomy of the biceps, unless the knife be care- 
fully introduced from within outwards. Below 
the knee the nerve can be felt close to the fibula 
just below the head, and when pressed upon in 
this situation causes a sensation to run down its 
branches to the foot. 

THE LEG AND ANKLE. 

115. Bony Points. — The tubercle of the tibia 
(for the attachment of the ligamentum patellae), 
the sharp front edge called the shin, and the 
broad flat subcutaneous surface of the bone can 
be felt all the way down. The inner edge can be 
felt too, but not so plainly. The lower third is 
the narrowest part of the bone and the most 
frequent seat of fracture. 

The head of the fibula is a good landmark on 
the outer side of the leg, about one inch below 
the top of the tibia and nearly on a level with the 
tubercle. Observe that it is placed well back, and 
that it forms no part of the knee-joint, and takes 
no share in supporting the weight. 

The shaft of the fibula arches backwards, the 



THE LEG AND ANKLE. Ill 

reverse of the shaft of the tibia. The fact of the 
bones not being on the same plane should be re- 
membered in flap amputations. The shaft of the 
fibula is so buried amongst the muscles, that the 
only part to be distinctly felt is the lower fourth. 
Here there is a flat triangular subcutaneous sur- 
face, between the peroneus tertius in front, and 
the two peronei (longus and brevis) behind. Here 
is the most frequent seat of fracture. 

116. Malleoli. — The shape and relative position 
of the malleoli should be carefully studied, as 
the great landmarks of the ankle. The inner 
malleolus does not descend so low as the outer, 
and advances more to the front: at the same time, 
owing to its greater antero-posterior depth, it is 
on the same plane as the outer behind. The 
lower border of the inner malleolus is somewhat 
rounded, and the slight notch in it for the attach- 
ment of the lateral ligament can be felt. The 
outer malleolus descends lower than the inner, 
thus effectually locking the joint on the outer side. 
Its shape is not unlike the head of a serpent. 
Viewed in profile, it lies just in the middle of the 
joint. 

In Syme's amputation of the foot at the ankle, 
the line of the incision should run from the apex 
of the outer malleolus, under the sole to the centre 
of the inner. 



11.2 THE LEG AND ANKLE. 

In a well-formed leg, the inner edge of the 
patella, the inner ankle, and the inner side of the 
great toe, should be in the same vertical plane. 
Look to these landmarks in adjusting a fracture 
or dislocation, keeping at the same time an eye 
upon the conformation of the opposite limb. 

[In consequence of violence, usually a sprain, a 
sliver of the internal surface of the thick malleoli 
may be broken off, seriously implicating the joint, 
but yet not perceptible by mobility, crepitus, or 
otherwise, from the exterior. Mr. Callender has 
happily named such, "sprain-fractures." 

Into the inter-malleolar space the astragalus is 
tightly wedged or mortised, and we have here, as 
I pointed out some years ago, a valuable means of 
diagnosis in case of Pott's fracture of the fibula 
three or four inches above the external malleolus. 
In such a fracture this inter-malleolar space is 
widened. If now the leg be seized by one hand 
above the ankle, and the foot by the other, with 
the palm under the sole, the thumb and fingers 
will have the astragalus in their grasp. The 
astragalus can then be pushed sidewise against 
the outer malleolus and then shoved suddenly 
towards the firm inner malleolus, against which 
it will come with an easily-perceived impact if 
there be fracture. If none exist, the astragalus 
will have no lateral play. Motion at the medio- 



THE LEG AND ANKLE. 113 

tarsal joints must not be mistaken for this tibio- 
tarsal movement.] 

There are several strong tendons to be seen and 
felt about the ankle. 

117. Tendo Achillis. — Behind is the tendo 
Achillis. It forms a high relief, with a shallow- 
gutter on each side of it. The narrowest part 
of the tendon, where it should be divided in 
tenotomy, is about the level of the inner ankle ; 
below this it expands again to be attached to the 
lower and back part of the os calcis. Seen in 
profile, the tendon is not straight, but slightly 
concave — being drawn in by an aponeurosis which 
forms a sort of girdle around it. This girdle 
proceeds from the posterior ligament of the ankle; 
and, though most of its fibres encircle the tendon, 
some of them adhere to and draw in its sides. All 
this disappears when the tendon is laid bare by 
dissection. 

118. Tendons behind Inner Ankle. — Above 
and behind the malleolus internus we can feel the 
broad flat tendon of the tibialis posticus and 
upon it that of the flexor longus digitorum. The 
tendon of the tibialis posticus lies nearest to the 
bone and comes well up in relief in adduction of 
the foot. It lies close to, and parallel with, the 
inner edge of the tibia, so that this edge is the 
best guide to it. Therefore in tenotomy the knife 

10* 



114 THE LEG AND ANKLE. 

should be introduced first perpendicularly between 
the tendon and the bone, and then turned at 
right angles to cut the tendon. The tendon has a 
separate sheath and synovial membrane, which 
commences about one inch and a half above the 
apex of the malleolus, and is continued to its 
insertion into the tubercle of the scaphoid bone. 
The proper place, then, for division of the tendon, 
is about two inches above the end of the malleolus. 

In a young and fat child, where the inner edge 
of the tibia cannot be distinctly felt, the best 
guide to the tendon is a point midway between 
the front and the back of the ankle. An incision 
in front of this point might injure the internal 
saphena vein ; behind this point, the posterior 
tibial artery. 

119. Tendons behind Outer Ankle.— Behind 
the malleolus externus we feel the two peroneal 
(long and short) tendons. They lie close to the 
edge of the fibula, the short one nearer to the 
bone. In dividing these tendons, the knife should 
be introduced perpendicularly to the surface, and 
about two inches above the apex of the ankle, so 
as to be above the synovial sheaths of the tendons. 

Tendons in front of Ankle. — Over the front 
of the ankle, when the muscles are in action, we 
can see and feel, beginning on the inner side, the 
tendons of the tibialis anticus, the extensor longus 



THE LEG AND ANKLE. 115 

pollicis, the extensor longus digitorum, and the 
peroneus tertius. They start rip like cords when 
the foot is raised, and are kept in their proper 
relative position by strong pulleys formed by the 
anterior annular ligament. Of these pulleys the 
strongest is that of the extensor communis digi- 
torum. When the ankle is sprained, the pain and 
swelling arise from a stretching of these pulleys 
and effusion into their synovial sheaths. A lacera- 
tion of one of the pulleys and escape of the tendon 
is extremely rare. 

The place for the division of the tendon of the 
tibialis anticus, so as to divide it below its syno- 
vial sheath, is about one inch before its insertion 
into the cuneiform bone. The knife should be 
introduced on the outer side, so as to avoid the 
dorsal artery of the foot. 

[Most of these tendons can be best seen by 
standing a model on one foot, i. e., in unstable 
equilibrium.] 

Now trace the lines of the arteries, and the 
landmarks near which they divide. 

120. Popliteal Artery. — About one inch and 
a quarter below the head of the fibula, or say one 
inch below the tubercle of the tibia, the popliteal 
artery divides into the anterior and posterior 
tibial. The peroneal comes off from the posterior 



116 THE LEG AND ANKLE. 

tibial about three inches below the head of the 
fibula. 

Consequently we may lay down, as a general 
rule, that, in amputations one inch below the head 
of the fibula, only one main artery, the popliteal, 
is divided. In amputations two inches below the 
head of the fibula, two main arteries, the anterior 
and posterior tibial, are divided. In amputations 
three inches below the head, three main arteries, 
the two tibials and the peroneal, are divided. 

121. Anterior Tibial Artery. — The anterior 
tibial artery comes in front of the interosseous 
membrane, one inch and a quarter below the head 
of the fibula, and here lies close to this bone. Its 
subsequent course is defined by a line drawn from 
the front of the head of the fibula to the middle 
of the front of the ankle. This line corresponds 
pretty nearly with the outer border of the tibialis 
anticus all the way down. If this muscle be put 
in action, its outer border (the intermuscular line) 
is plainly seen, and the incision for the ligature of 
the artery in any part of its course may be defined 
with the greatest precision. The artery can be felt 
beating and can be compressed where it crosses the 
front of the tibia and ankle. 

122. Posterior Tibial Artery. — The posterior 
tibial commences about one inch and a quarter 
below the head of the fibula. Its subsequent 



THE LEG AND ANKLE. 117 

course corresponds with a line drawn from the 
middle of the upper part of the calf to the hollow 
behind the inner ankle, where it can be felt beat- 
ing distinctly about half an inch behind the edge 
of the tibia. A vertical incision down the middle 
of the calf would reach the artery under cover of 
the gastrocnemius and soleus. A vertical incision 
along the middle third of the leg, about half an 
inch from the inner edge of the tibia, would 
enable the operator to reach the artery sideways, 
by detaching from the bone the tibial origin of 
the soleus. 

[The posterior tibial artery, behind the malle- 
olus, lies midway between the tendo Achillis, or 
the heel, and the malleolus. It is the middle of 
five structures : in front of it are, (1) the tibialis 
posticus tendon, (2) the flexor longus digitorum 
tendon ; behind it are (4) the posterior tibial nerve 
and (5) the flexor longus pollicis tendon. It is 
important to observe that, as Wyeth has shown, 
it bifurcates into the two plantar arteries at a line 
drawn from the point of the malleolus to the 
middle of the heel.] 

123. Saphena Veins. — The subcutaneous veins 
on the dorsum of the foot form an arch convex 
towards the toes (as on the back of the hand), 
from which issue the two main subcutaneous 
trunks of the lower limb, the internal and external 



118 THE FOOT. 

saphena veins. The internal vein can be always 
plainly seen over the front of the inner ankle. Its 
farther course up the inner side of the leg, knee, 
and thigh to its termination in the femoral is not 
in all persons manifest. 

[It lies about half an inch behind the internal 
border of the tibia, skirts the knee postero- 
internally, and, passing up the inside of the 
thigh, empties at the saphenous opening into the 
femoral. A thrombus not uncommonly may form 
in it, or in the femoral, or may extend from it 
into the femoral. The careful investigation of 
both veins then becomes very important, and is 
not generally difficult, especially if we remember 
the course of the saphena and the relation of the 
femoral to its artery.] 

The external saphena vein runs behind the 
outer ankle and up the middle of the calf to 
empty itself (generally) into the popliteal vein. 

THE FOOT. 

What are the bony landmarks which guide us 
in the surgery of the foot? 

124. Points of Bone. — Along the inner side of 
the foot, beginning from behind, we can feel — 1, 
the tuberosity of the os calcis; 2, the projection 
of the internal malleolus ; 3, the projection of the 



THE FOOT. 119 

os calcis, termed "sustentaculum tali," about one 
full inch below the malleolus; 4, about one inch 
in front of the malleolus internus, and a little 
lower, is the tubercle of the scaphoid bone ; the 
gap between it and the sustentaculum tali being 
filled by the calcaneo-scaphoid ligament and the 
tendon of the tibialis posticus, in which there is 
often a sesamoid bone ; 5, the internal cuneiform 
bone ; 6, the projection of the first metatarsal 
bone ; 7, the sesamoid bones of the great toe. 
[On a line nearly midway from the scaphoid to 
the inner malleolus the head of the astragalus 
can be felt. In front, with the foot in extension, 
we can feel also the upper and lateral articular 
surfaces of the astragalus, and especially the 
ridges between them.] 

Along the outer side of the foot we can feel — 1, 
the external tuberosity of the os calcis ; 2, the 
external malleolus; 3, the peroneal tubercle of the 
os calcis, one inch below the malleolus, with the 
long peroneal tendon below it, and the short one 
above it; 4, the projection of the base of the fifth 
metatarsal bone. 

125. Lines of Joints. — In fat persons the fol- 
lowing rules for finding the joints may be of ser- 
, vice as regards the surgery of the foot : — 

The level of the ankle joint lies about half an 
inch above the end of the inner malleolus. This 



120 THE FOOT. 

is worth remembering in performing " Syme's" 
amputation. 

The tubercle of the scaphoid bone is the best 
guide to the astragalo-scaphoid joint which lies 
immediately behind it ; and the plane of this joint 
is in the same line as that of the calcaneo-cuboid. 
Thus a line drawn transversely over the dorsum 
of the foot, behind the tubercle of the scaphoid, 
would strike both the joints opened in "Chopart's" 
operation. 

Place your thumb on the tubercle of the sca- 
phoid, and measure about one inch and a half 
in front: here you find the joint between the 
internal cuneiform bone and the metatarsal bone 
of the great toe. This point is useful in Lisfranc's 
operation, which consists in the removal of the 
metatarsal bones. 

The line of the calcaneo-cuboid joint lies midway 
between the external malleolus and the (tarsal) end 
of the metatarsal bone of the little toe. 

The projection of the fifth metatarsal bone is 
the guide to the joint between it and the cuboid. 

Notice that the line of the joints between the 
metatarsal bones and the first phalanges lies a full 
inch farther back than the interdigital folds of 
the skin. This is a point to be remembered in 
amputating the toes. 



THE FOOT. 121 

126. Dorsal Artery. — The line of the dorsal 
artery of the foot is from the middle of the ankle 
to the interval between the first and second meta- 
tarsal bones. The artery can be felt beating over 
the bones along the outer side of the extensor 
longus pollicis, which is the best guide to it. 

127. Bursa. — The synovial sheath of the ex- 
tensor longus pollicis extends from the front of 
the ankle, over the instep (apex of the internal 
cuneiform bone) as far as the metatarsal bone of 
the great toe. There is generally a bursa over the 
instep, above, or it may be, below, the tendon. 

There is often a large irregular bursa between 
the tendons of the extensor longus digitorum, and 
the projecting end of the astragalus, over which 
the tendons play. There is much friction here. 
It is well to be aware that this bursa sometimes 
communicates with the joint of the head of the 
astragalus. 

128. Plantar Arteries. — The course of the 
external plantar artery corresponds with a line 
drawn from the hollow behind the inner ankle 
obliquely across the sole nearly to the base of the 
fifth metatarsal bone ; from thence the artery tarns 
transversely across the foot, lying (deeply) near the 
bases of the metatarsal bones, till it inosculates 
with the dorsal artery of the foot in the first 
interosseous space. 

11 



122 THE ARM. 

The course of the internal plantar corresponds 
with a line drawn from the inner side of the os 
calcis to the middle of the great toe. 

129. Plantar Fascia. — To divide the plantar 
fascia subcutaneously, the best place is about one 
inch in front of its attachment to the os calcis. 
This is the narrowest part of it. The knife should 
be introduced on the inner side; arid the incision 
will be behind the plantar artery. 

The subcutaneous section of the tendon of the 
abductor pollicis should be made about one inch 
before its insertion. 

[It is evidently the opinion of shoemakers that 
the axis of the sole of the foot ought to be a 
median straight line, and the two borders sym- 
metrically curved towards it. If a foot they have 
not unduly distorted be observed carefully, it will 
be seen (B. Lee) that the axis is curved ; that on 
the inner border of the foot, the heel, and the 
front part of the foot are in nearly a straight line, 
while the outer border is a curved line. If nature 
be followed, natural shaped feet will be the result, 
and the miseries of corns and bunions be unknown.] 

THE ARM. 

130. Clavicle. — The line of the clavicle and 
the projection of the joint at either end can always 



THE ARM. 123 

be felt, even in the fattest persons. Its direction 
is not perfectly horizontal, but slightly inclined 
downwards, when the arm hangs quietly by the 
side. When the body lies flat on the back, the 
shoulder not only falls back, but rises a little, 
the weight of the limb being taken off. Hence 
the modern practice of treating fractures of the 
clavicle (in the early stage) by the supine position. 

On the front surface of the clavicle, not far 
from its acromial end, there is in many persons of 
mature age a spine-like projection of bone. So 
far as I know, it has not been described. A 
gentleman, himself a surgeon, showed me an 
instance in his own person. He suspected it was 
an exostosis. 

As a rule the acromio-clavicular joint forms an 
even plane. But there is sometimes a knob of 
bone at the acromial end of the clavicle ; or it 
may be only a thickening of the flbro-cartilage, 
sometimes existing in the joint. In either case 
this relief might be mistaken for a dislocation, or 
even for a fracture. A reference to the other 
shoulder might settle the question. 

[Being subcutaneous throughout, the clavicle 
can readily be seized and examined for fracture, 
syphilitic nodes, etc. If before a glass the arm be 
swung round, raised and lowered, the shoulder be 
shrugged, etc., we shall appreciate the fact that 



124 THE ARM. 

this is the only bony connection the arm has with 
the body, and to what a very large extent it is 
movable, the sterno-clavicular joint being the 
pivot.] 

131. Bony Points of the Shoulder. — We 
can distinctly feel the spine of the scapula and 
the acromion, more especially at the angle where 
they join behind the shoulder. This angle is the 
best place from which to measure in taking the 
comparative length of the arms. 

In some shoulders, though very rarely, there is 
an abnormal symphysis between the spine of the 
scapula and the acromion. There may indeed 
be two symphyses and two acromial bones, the 
acromion having two centres of ossification. These 
normal symphyses might be mistaken for fractures, 
until we have examined the opposite shoulder, 
which is sure to present a similar conformation. 1 

Tuberosities. — Projecting beyond the acromion 
(the arm hanging by the side), we can feel, through 
the fibres of the deltoid, the upper part of the 
humerus. It distinctly moves under the hand 
when the arm is rotated. It is not the head of the 
bone which is felt, but the tuberosities, the greater 
externally, the lesser in front. These tuberosities 

1 See Pruge on " Ossa Acromialia" (" Zeitschrift fur ration- 
elle Medizin"), 3. Reihe, Bd. vii., 1859. 



THE ARM. 125 

form the convexity of the shoulder. When the 
arm is raised, this convexity disappears ; there is 
a slight depression in its place. The head of the 
bone can be felt by pressing the fingers high np in 
the axilla. 

The absence of this prominence formed by the 
upper part of the humerus under the deltoid, and 
the presence of a prominence low in the hollow of 
the axilla, or in front, below the coracoid process, 
or behind, on the back of the scapula, bespeak 
dislocation of the head of the bone. 

In examining obscure injuries about the shoul- 
der, it is worth remembering that, in the normal 
relation of the bones, and in every position, the 
great tuberosity faces in the direction of the ex- 
ternal condyle. The head of the bone faces very 
much in the direction of the internal condyle. 

It is worth remembering also that the upper 
epiphysis of the humerus includes the tuberosities ; 
and that it does not unite by bone to the shaft, till 
about the 20th year. 

By making deep pressure in front of the shoul- 
der, when the arm is pendent and supine, we can 
feel the bicipital groove [between the two tuberosi- 
ties]. It looks directly forwards, and runs in a line 
drawn vertically downwards through the middle 
of the biceps to its tendon at the elbow. We 
11* 



126 THE ARM. 

should be aware of this, lest it be mistaken for a 
fracture. 

132. Coraco- Acromial Ligament,— Under the 

anterior fibres of the deltoid, we can distinctly feel 
the position and extent of the coraco-acromial 
ligament. A knife, passed vertically through the 
middle of it, goes at once into the shoulder joint 
and strikes the bicipital groove with the tendon, a 
point to be remembered in excision. 

In persons of an athletic build the triangular 
form and beautiful structure of the deltoid become 
conspicuous when the muscle is in action. The 
depression on the outer side of the arm, indicating 
its insertion, is the place selected for issues or 
setous. 

The arm being held up by an assistant, the 
anterior and posterior borders of the relaxed del- 
toid admit of being raised so that in amputation at 
the shoulder the knife can be introduced beneath 
the muscle to make the flap. 

133. Axilla. — [To show its borders best, let the 
model place his elbow on your shoulder and press 
down upon it, when the muscles will be brought 
into strong relief] The anterior border of the 
axilla, formed by the pectoralis major, follows the 
line of the fifth rib. In counting the ribs, or in 
tapping the chest, it is worth remembering that the 
highest visible digitation of the serratus magnus 



THE ARM. 127 

is attached to the sixth rib. The angle of the 
digitation is directed forwards, and corresponds to 
the upper edge of the rib. The second visible 
digitation corresponds to the seventh rib ; the in- 
terval between these digitations, therefore, corre- 
sponds to the sixth intercostal space — a convenient 
place for tapping the chest. (38) 

In the normal state no glands can be felt in the 
axilla. [But in feeling to see if they are enlarged, " 
remember that they lie next the chest, at the 
inner, and not the outer, wall of the axilla; a fact 
which facilitates also their removal.] 

134. Axillary Artery. — When the arm is 
raised to a right angle with the body, and the head 
of the humerus thereby depressed, the axillary 
artery is plainly felt beating, and can be perfectly 
compressed on the inner side of the coraco-brachi- 
alis. This muscle stands out in relief along the 
humeral side of the axilla, and is the best guide 
to the artery. A line drawn along its inner 
border — that is, down the middle of the axilla — 
corresponds with the course of the artery. 

The depth and form of the axilla alter in dif- 
ferent positions of the arm. In the arm raised and 
abducted the axilla becomes nearly flat; hence this 
position is always adopted in operations. 

In opening abscesses in the axilla, the incision 
should be made midway between the borders, and 



128 THE ARM. 

the point of the knife introduced from above 
downwards. 

135. Brachial Artery. — When the arm is ex- 
tended and supinated, a line drawn from the deepest 
part of the middle of the axilla down the inner 
side of the biceps to the middle of the bend of the 
elbow, corresponds with the course of the brachial 
artery. The artery can be felt and compressed all 
the way down ; but nowhere so effectually as 
midway, where it lies on the tendon of the coraco- 
brachial close to the inner side of the humerus. 
The only direction to apply the pressure effectually 
is outwards and a little backwards, else the artery 
will slip off the bone. [A high bifurcation very 
often occurs, and would probably be perceptible on 
careful examination. 

The median nerve lies to the outside of the 
artery above, crosses it, usually in front, at the 
middle, and lies to the inside below. It can 
usually be felt and very easily differentiated from 
the artery.] 

The musculo-spiral nerve and superior profunda 
artery wind round the back of the humerus about 
its middle, and come to the front of the external 
condyloid ridge [in the groove between the supi- 
nator longus and the brachialis anticus, where it 
is accessible to the battery and in operations]. 
Thus, for full three inches above the condyles, 



THE ARM. 129 

there is nothing to interfere with operations on the 
back of the bone, which is here broad and flat. 

136. Bend of Elbow.— At the bend of the 
elbow, the tendon of the biceps can be plainly felt, 
as well as the pulsation of the brachial artery close 
to its inner side, before dividing into the radial 
and ulnar. [If the arm be strongly flexed at a 
right angle, by attempting to lift a heavy table, 
for instance, the bicipital fascia can be outlined by 
the finger, and in many persons by the eye.] 

Cutaneous Veins. — The bend of the elbow in 
young children and in persons with fat and round 
arms, presents a semicircular fold of which the 
curve embraces the lower part of the biceps; but 
in muscular persons we see the distinct boundaries 
of the triangular space, formed by the pronator 
teres on the inner side, and the supinator longus 
on the outer. Here can be traced, standing out 
in strong relief under the thin white skin, the 
superficial veins, which, in days gone by, when 
bloodletting was the fashion, were of such great 
importance. Their arrangement, although subject 
to variety, is very much like the branches of the 
letter M, the middle of the M being at the middle 
of the elbow. Of these branches the median 
basilic, which runs over the tendon of the biceps, 
is the largest and most conspicuous, and is gene- 
rally selected for venesection; it crosses the course 



130 THE ARM. 

of the brachial artery, nothing intervening but 
the semilunar aponeurosis from the tendon of the 
biceps. 

137. Landmarks of Elbow.— It is of great 
importance to be familiar with the relative posi- 
tions of the various bony prominences about the 
elbow. We can always feel the internal and ex- 
ternal condyles. The internal is the more promi- 
nent of the two, and a trifle higher. 

Olecranon. — We can always feel the olecranon. 
This is somewhat nearer to the inner than to the 
outer condyle. [On strong flexion, the groove in 
the humerus for the olecranon can be readily felt, 
and even seen.] Between the olecranon and the 
internal condyle is a deep depression in which lies 
the ulnar nerve (vulgarly called the "funny bone"). 

On the outer side of the olecranon, just below 
the external condyle, is a pit in the skin, constant 
even in fat persons (when the elbow is extended). 
This pit is considered one of the beauties of the 
elbow in a graceful arm ; it is seen in a child as a 
pretty little dimple. To the surgeon it is most 
interesting, as in this valley behind the supinator 
longus and the radial extensors of the wrist he 
can distinctly feel the head of the radius rolling in 
pronation and supination of the forearm. It is, 
therefore, one of the most important landmarks 
of the elbow, since it enables us to say whether 



THE ARM. 131 

the head of the radius is in its right place, and 
whether it rotates with the shaft. 

Can the tubercle of the radius be felt? Yes, 
but only on the back of the forearm in extreme 
pronation. Its projection is then distinctly per- 
ceptible just below the head of the bone. 

Relations of Olecranon and Condyles.— To 
examine the relative positions of the olecranon 
and condyles in the different motions of the elbow- 
joint, place the thumb on one condyle, the tip of 
the middle finger on the other, and the tip of the 
forefinger on the olecranon. In extension, the 
highest point of the olecranon is never above the 
line of the condyles; indeed, it is just in this line. 
With the elbow at right angles the point of the 
olecranon is vertically below the line of the con- 
dyles. In extreme flexion the point of the ole- 
cranon lies in front of the line of the condyles. 

All these relative positions would be altered in 
the dislocation of the ulna, but not (necessarily) in 
a fracture of the lower end of the humerus. 

Sometimes, though rarely, we meet with a hook- 
like projection of bone above the internal condyle. 
It is called a "supra- condyloid" process; it can be 
felt through the skin, with its concavity down- 
wards, and is a rudiment of the bony canal which, 
in many mammalia, transmits the median nerve 
and ulnar artery. A third origin of the pronator 



132 THE ARM. 

teres is always attached to it ; this origin covers 
the brachial artery. 1 

BurS8B. — The subcutaneous bursa over the ole- 
cranon, if distended, would be as large as a walnut. 
A second bursa sometimes exists a little lower 
down upon the ulna. There is also a small sub- 
cutaneous bursa over each of the condyles. 

The vertical extent of the elbow-joint is limited, 
above by a line drawn from one condyle to the 
other; below, by a line corresponding to the lowest 
part of the head of the radius. 

138. Interosseous Arteries. — About one inch 
below the head of the radius, the ulnar artery 
gives off the common interosseous; and this divides, 
about half an inch lower, into the anterior and 
posterior interosseous. Thus, in amputating the 
forearm, say two inches below the head of the 
radius, four arteries at least would require ligature. 

By flexion of the elbow to the utmost, the circu- 
lation through the brachial artery can be arrested; 
but the position is painful, and can be tolerated 
only for a short time. 

Lymphatic Gland.— There is a small lymph- 
atic gland just above the inner condyle, in front of 
the intermuscular septum. It is the first to take 
alarm in poisoned wounds of the hand. 

1 See on this subject a monograph, " Canalis Supra-Con- 
dyloideus Humeri." By W. Grliber. Petersburg, 1856. 



THE FOREARM AND WRIST. 133 

TEE FOREARM AND WRIST. 

139. Ulna. — The edge of the ulna can be felt 
subcutaneous from the olecranon to the styloid 
process (in supination). Any irregularity could 
be easily detected. The styloid process of the 
ulna does not descend so low as the styloid process 
of the radius, or it would impede the free abduc- 
tion of the hand. Its apex is on a level with the 
radio-carpal joint. The head of the ulna is plainly 
felt and seen projecting at the back of the wrist, 
especially in pronation of the forearm. It then 
lies between the tendons of the extensor carpi 
ulnaris and extensor minimi digiti. There is often 
a subcutaneous bursa over it. [In supination, it is 
the styloid process, and not the head of the ulna, 
which is felt posteriorly.] 

140. Radius. — The upper half of the shaft of 
the radius is so covered by muscles that we cannot 
feel it ; the lower half is more accessible to the 
touch, especially just above and just below the 
part where it is crossed by the extensors of the 
thumb. Its styloid process is readily felt, and 
made all the more manifest by being covered by 
the first two extensor tendons of the thumb. It 
descends lower, and lies more to the front than the 
corresponding process of the ulna. The relative 
positions of these styloid processes can be best 

12 



134 THE FOREARM AND WRIST. 

examined by placing the thumb on one and the 
forefinger on the other. 

Feel for the little bony pnlley on the back of 
the radius near the wrist, which keeps in place the 
third extensor tendon of the thumb. This and the 
bone just above it is the place which we examine 
for a suspected fracture (termed Colles's) near the 
lower end of the radius. 

141. Carpus. — Below the styloid process of the 
radius, just on the inner side of the extensors of 
the thumb, we feel the tubercle of the scaphoid 
bone. Between the styloid process and the tubercle 
is the level of the radio-carpal joint. A little lower 
we feel the trapezium. 

Just below the ulna on the palm of the hand we 
feel the pisiform bone ; and on the inner side of 
this, the cuneiform. 

There are several transverse furrows on the 
palmar aspect of the wrist. The lowest of these, 
which is slightly convex downwards, corresponds 
with the upper edge of the anterior annular liga- 
ment and the intercarpal joint. The line of the 
raido-carpal joint, as already stated, is on a level 
with the apex of the styloid process of the ulna. 

In forcible [and resisted] flexion of the wrist, 
the tendon of the flexor carpi radialis and that 
of the palmaris longus come up in relief. On the 
outer side of the first-named tendon we feel the 



THE FOREARM AXD WRIST. 135 

pulse, the radial artery here lying close to the 
radius. 

The tendon of the palmaris longus runs near the 
middle of the wrist, and close to its inner border 
runs the median nerve. In letting out deep-seated 
matter near the wrist, the incision should be made 
close to and parallel with the inner edge of the 
radial flexor tendon, so as to avoid injury to the 
median nerve. [The median nerve in the forearm 
lies under the flexor sublimis digitorum, in a line 
drawn from the bend of the elbow just inside the 
artery to a point between the tendons of the 
palmaris longus and the flexor carpi radialis. It 
is here not only amenable to operations, but often 
is cut in accidents.] 

We can feel the tendon of the flexor carpi 
ulnaris for some distance above the wrist. It 
overlies the ulnar artery, and somewhat masks its 
pulsation. 

142. Pulse.— The "pulse at the wrist" is felt 
just outside the tendon of the flexor carpi radialis. 
In feeling the pulse it should be remembered that, 
in some cases, the superflcialis vola3 arises higher 
and is larger than usual. In such cases it runs by 
the side of the radial artery, and gives additional 
volume to the pulse. The old writers call it "pul- 
sus duplex." When in doubt, therefore, it is well 
to feel the pulse in each wrist. 



136 THE FOREARM AND WRIST. 

143. Great Carpal Bursa. — The great synovial 
sheath under the annular ligament common to the 
flexor tendons of the Angers and the long flexor 
of the thumb, extends, upwards, about an inch 
and a half above the edge of the ligament, and, 
downwards, as low as the middle of the palm. 
This general synovial sheath communicates with 
the special sheaths of the thumb and the little 
finger ; not with that of the index, middle, and 
ring fingers. 

144. "Tabatiere Anatomique." — On the 
outer side of the wrist we can distinctly see and 
feel, when in action, the three extensor tendons of 
the thumb. Between the second and third there is 
deep depression, at the root of the thumb, which 
the French humorously call the " tabatiere anato- 
mique." In this depression we can make out — 1, 
the relief of the superficial radial vein ; 2, the 
radial artery, in its passage to the back of the 
hand; 3, the upper end of the metacarpal bone of 
the thumb. 

145. Tendons on Back of Wrist. — The rela- 
tive positions of the several extensor tendons of 
the wrist and fingers, as they play in their grooves 
over the back of the radius and ulna, can all be 
distinctly traced when the several muscles are put 
in action. The length of their synovial sheaths 
should be remembered. They vary from one inch 



THE FOREARM AND WRIST. 137 

and a half to two inches and a half. The longest 
of all are those of the extensors of the thumb. 
When these sheaths are inflamed and swollen, the 
motion of the tendons becomes painful and gives 
rise to a feeling of crepitus, called "tenalgia crepi- 
tans" by some writers. It is said to be met with 
sometimes in pianists. [On the overstretching of 
these muscles, see § 111.] 

146. Lines of Arteries. — The course of the 
radial artery corresponds with a line drawn from 
the outer border of the tendon of the biceps at the 
bend of the elbow down tke front of the forearm 
to the front of the styloid process of the radius. 
In the upper third of its course the artery is over- 
lapped by the supinator longus. To make allow- 
ance for this, the incision for the ligature of the 
artery in this situation should be made, not pre- 
cisely in the line of its course, but rather nearer 
the middle of the forearm. 

The line of the ulnar artery runs from the 
middle of the bend of the elbow (slightly curving 
inwards) to the outer side of the pisiform bone. 
The radial and ulnar arteries can, in most cases, be 
effectually commanded by pressure well applied at 
the wrist, in wounds of the palmar arch. 

Before we make incisions along the forearm, it 
is always desirable to ascertain whether the ulnar 
artery, which usually runs under the superficial 

12* 



138 THE HAND. 

muscles, may not run abnormally over them ; in 
which case its pulsations can be felt all down the 
forearm. 

THE HAND. 

147. It is beside the purpose here to examine 
the question whether the hand can tell more than 
the arm, the leg, or any other part of the body, 
about the physical constitution of its owner, and to 
what use it has been put. Those who are interested 
in this subject should read a very elaborate treatise 
by Carus, 1 " On the Eeason and Meaning of the 
Different Forms of the Hand." Still less would I 
indulge curiosity by inquiring whether the pro- 
fessors of chiromancy, relying on the text "erit 
signum in manu tua et quasi monumentum ante 
oculos tuos," can advance any reasonable preten- 
sions for their assertion that they can read in the 
furrows of the palm the future destiny of its 
master. 

148. Furrow in Palm. — The only furrow in 
the palm useful as a surgical landmark is that 
which runs transversely across its lower third 
[from the ulnar border to the interspace between 
the fore- and middle-fingers], and is well seen when 



1 " Ueber Grand und Bedeutung der verschiedenen Formen 
der Hand." Stuttgart, 1846. 



THE HAND. 139 

the fingers are slightly bent. This transverse fur- 
row corresponds pretty nearly with the metacarpal 
joints of the fingers, with the upper limit of the 
synovial sheaths of the flexor tendons of the 
fingers (that of the little finger excepted (143) ) ; 
also with the splitting of the palmar fascia into its 
four slips. The transverse metacarpal ligament 
lies in the same line with it. Again, a little below 
this furrow, the digital arteries bifurcate to run 
along the opposite sides of the fingers. 

149. Interdigital Folds, — By pressing upon 
the interdigital folds of skin, we can feel the 
transverse ligament of the fingers, which prevents 
their too wide separation. The skin of these folds 
is much thinner on the dorsal than the palmar 
aspect ; hence deep-seated abscesses in the palm 
very frequently burst on the back of the hand. 

150. Digital Furrows. — Concerning the trans- 
verse furrows on the palmar surface of the fingers, 
notice that the first furrows, close to the palm, do 
not correspond with the metacarpal joints. The 
second and third furrows do correspond with their 
respective joints. 

The slight depression observable between the 
ball of the thumb and that of the little finger cor- 
responds with the middle of the anterior annular 
ligament. 



140 THE HAND. 

151. Palmar Arterial Arches. — In opening 
abscesses in the palm, it is important to bear in 
mind the position of the large arterial arches 
which lie beneath the palmar fascia. The line of 
the superficial palmar arch crosses the palm about 
the junction of the upper with the lower two- 
thirds — that is, in the line of the thumb separated 
widely from the fingers. From this, the digital 
arteries run straight between the shafts of the 
metacarpal bones towards the clefts of the fingers. 
Incisions, therefore, to let out pus beneath the 
palmar fascia may safely be made in the lower 
two-thirds of the palm, provided they run in the 
direction of the middle line of the fingers. The 
deep palmar arch lies half an inch nearer the wrist 
than the superficial. 

152. Digital Arteries. — As the digital arteries 
run along the sides of the fingers, the incision to 
open a thecal abscess should be made strictly in 
the middle line. It should be made not over but 
between the joints, since the sheath is strongest 
and thickest over the shafts of the phalanges, and 
therefore more likely to produce strangulation of 
the inclosed tendons. 

153. Metacarpal Joint of Thumb.— The joint 
of the metacarpal bone of the thumb with the 
trapezium can be distinctly felt by tracing the 
dorsal surface of the bone upwards till we come 



THE HAND. 141 

to the prominence which indicates the joint at 
the bottom of the "tabatiere anatomique" (140). 
Supposing, however, there be much swelling, the 
knife introduced at the angle between the first and 
second metacarpal bones readily finds the joint if 
the blade be directed outwards. 

154. Sesamoid Bones. — The sesamoid bones of 
the thumb can be distinctly felt. Just above them 
— that is, nearer to the wrist — lies the joint be- 
tween the metacarpal bone and the first phalanx. 
We should remember the position of these bones 
in amputation at this joint. Mutatis mutandis the 
same observations apply to the sesamoid bones of 
the great toe. 

The extensor tendon of the last joint of the 
thumb crosses the apex of the first interosseous 
space. Under the tendon, and in the angle be- 
tween the bones, we feel the radial artery just 
before it sinks into the palm. 

155. Subcutaneous Veins. — The veins on the 
back of the hand, and their arrangement in the 
form of arches which receive the digital veins, is 
sufficiently obvious. The number and arrange- 
ment of the arches may vary, but in all hands it 
is interesting to notice that the veins from the 
fingers run up between the knuckles and out of 
harm's way. 

156. Interosseous Arteries. — Since the dorsal 



142 THE HAND. 

interosseous arteries, like the palmar, run along the 
interosseous spaces, incisions to let out pus should 
always be made along the lines of the metacarpal 
bones. 

157. Digital Bursse. — Small subcutaneous 
bursse are sometimes developed over the knuckles 
and the backs of the joints of the fingers. They 
often become enlarged and unseemly in persons of 
a rheumatic or gouty tendency. 

158. Knuckles and Digital Joints. — The 
three rows of projections called " the knuckles" 
are formed by the proximal bones of the several 
joints: thus the first row is formed by the ends of 
the metacarpals; the second by the ends of the 
first phalanges, and so forth. In amputations of 
the fingers it is well to remember that in all cases 
the line of the joints is a little in advance of the 
knuckles, that is, nearer the end of the fingers. 

Long and graceful fingers, coupled with thick- 
ness and breadth of the sentient pulp at their ends, 
and too great arching of the nails, have been re- 
garded, ever since the days of Hippocrates, as not 
unlikely indications of a tendency to pulmonary 
disease. 

[Staining the nails (e. g., by nitric acid) affords a 
means of determining the fact and the rate of their 
growth, and, therefore, of the nutritive processes 
in the corresponding arm or leg.] 



PALPATION BY THE EECTUM. 143 

PALPATION BY THE RECTUM. 

The following report is from Mr. Walsham, of 
St. Bartholomew's Hospital, who, having a small 
hand (somewhat less than seven and a half inches 
round), has had opportunities of introducing it up 
the rectum, in the living subject, for the purpose 
of diagnosis : — ■ 

"It is possible to introduce the hand (if small) 
into the rectum; in many cases into the sigmoid 
flexure, and in rare instances into the descending 
colon. 

"Once beyond the sphincter, the hand enters a 
capacious sac, and the following important parts 
can be felt through its walls : — 

" Through the anterior wall the hand first recog- 
nizes the prostate, which feels like a moderately 
large chestnut. Immediately behind the prostate, 
the vesicular seminales may be distinguished as two 
softish masses situated one on either side of the 
middle line. Internal to them, the whipcord-like 
feel of the vasa deferentia can be readily traced 
over the bladder to the sides of the pelvis. 

"The bladder is easy recognized, when mode- 
rately distended, as a soft fluctuating tumour 
behind the prostate ; when empty it cannot be 
distinguished from the intestines, which then 
descend between the rectum and the pabes. The 



114 PALPATION BY THE RECTUM. 

arch of the pubes can be well denned when the 
bladder is empty. 

"Through the posterior wall of the bowel the 
coccyx and sacrum can be felt, the curve of the 
sacrum being readily followed by the hand. 

"The projecting spine of the ischium on each 
side of the pelvis is a valuable landmark. From 
this point the outlines of the greater and lesser 
sacro-ischiatic foramina can be traced by the 
fingers ; and any new growth, encroaching on the 
pelvic cavity through these apertures, could be 
easily detected. 

"If the hand be now pushed farther up the 
gut, the promontory of the sacrum is reached ; the 
pulsation of the iliac vessels becomes manifest, 
and the course of the external iliac can be traced 
along the brim of the pelvis to the crural arch, the 
loose attachments of the rectum permitting very 
free movement in this direction. The internal 
iliac artery can also be followed to the upper part 
of the great sacro-ischiatic foramen. 

"By semi-rotatory movement, and alternately 
flexing and extending the fingers, the hand can 
gradually be insinuated into the commencement 
of the sigmoid flexure. In the sigmoid flexure 
the fingers can explore the whole of the lower 
part of the abdomen, the loose attachment of this 



PALPATION BY THE RECTUM. 145 

portion of the gut permitting the hand to travel 
freely over the iliac and hypogastric regions. 

"The parts that can here be felt are the bifurca- 
tion of the aorta, the division of the common iliac 
arteries, the iliac fossa, and the crest of the ilium. 

"In the female, the uterus in the middle line, 
and the ovaries on either side, can be readily dis- 
tinguished. 

"In the introduction of the hand into the rec- 
tum, in a patient under chloroform, the dilatation 
of the sphincter ani should be very gradual: first 
two fingers, then four, and finally the thumb 
should be passed. It is necessary to use con- 
siderable force, and unless care be taken, not only 
the integumentary edge of the anus, but the 
sphincter itself, may be lacerated. The introduc- 
tion is facilitated by the application of the other 
hand upon the abdomen. 

"When the dilatation has been gradual and the 
hand not too large, no incontinence of feces and no 
very considerable amount of pain has resulted. 

"We have been informed on reliable authority 
that permanent incontinence of feces has occasion- 
ally followed these examinations." 

Lastly, we think it right to insist upon the 

important fact that, in some subjects, even a small 

hand cannot be passed up the rectum beyond the 

reflection of the peritoneum over the second part 

13 



146 EXAMINATION PER VAGINAM. 

of the gut. In such instances the peritoneum 
offers a resistance like a tight garter, and prevents 
the farther advance of the hand without great risk 
of laceration of the parts. 1 

EXAMINATION PER VAGINAM. 

For this report I am indebted to Dr. Godson, of 
St. Bartholomew's Hospital : — 

"The finger introduced into the vagina comes 
upon the carunculas myrtiformes, which are vas- 
cular membranous processes independent of the 
hymen, variable in number, size, and form. It 
also feels the transverse ridges known as "rugae." 

"Along the anterior wall of the vagina the fin- 
ger readily detects the track of the urethra, which 
feels like a prominent cord and forms an excellent 
guide to the orifice of the meatus urinarius in 
passing a catheter. The orifice is indicated by a 
slight semicircular prominence, situated about one- 
third of an inch above the orifice of the vagina. 
Behind the urethra the finger comes upon the 
posterior wall of the bladder. But the bladder is 
not perceptible, as such, to the touch unless dis- 
tended. With a catheter previously introduced it 
is much more readily explored. 

1 For further information on this subject, see a paper by Mr. 
Walsham, in St. Bartholomew's Hospital Reports, vol. xii. 



EXAMINATION PER VAGINAM. 147 

"The septum between the vagina and the rectum 
is so thin that, should the rectum contain fecal 
matter, its presence becomes at once apparent to 
the finger. 

"The cervix uteri is felt protruding from the 
roof of the vagina in a direction downwards and 
backwards — that is, in a line from the umbilicus 
to the coccyx. The os uteri is felt, small and 
round, in the centre of the cervix. The posterior 
lip feels a little lower than the anterior. The cul- 
de-sac formed by the vagina in front and behind 
the cervix should be perfectly elastic to the touch, 
and not communicate the sensation of a resisting 
body. Any resistance here bespeaks an abnormal 
condition. 

"The bony landmarks within reach of a finger, 
or perhaps two, in a woman who has not borne a 
child, are the symphysis pubis, the rami of the 
pubes and ischia. The coccyx and part of the 
hollow of the sacrum may also be felt, but not 
without exerting much pressure on the posterior 
wall of the vagina, which gives considerable pain. 
If the promontory of the sacrum can be felt, it is 
a sign that the conjugate diameter of the pelvis is 
abnormal. 

" The finger in the rectum can detect almost 
everything which has been mentioned in connec- 
tion with the vagina. The shape and direction of 



148 EXAMINATION PER VAGINAM. 

the cervix uteri are almost as perceptible, and the 
posterior wall of the uterus can be examined. 
The peritoneal fold termed recto-vaginal (Doug- 
las's space) can also be well explored, and any- 
thing abnormal detected in this direction — a point 
of great importance in the diagnosis of diseases 
and displacements of the uterus. 

"The ovary in its normal state and position 
cannot be detected by the touch even with the 
hand firmly pressed on the hypogastrium. If a 
movable body be felt through the vaginal roof on 
one side of the cervix, if this body be exquisitely 
tender and recede at once from the finger, it is an 
ovary in a state of prolapse. 

"The fundus of a healthy unimpregnated uterus 
never rises above the level of the brim of the 
pelvis, and cannot therefore be felt by pressing the 
hand on the hypogastrium. 

" The direction of the uterus is subject to 
changes which cannot be looked upon as abnor- 
mal. The fundus may be thrown backwards by 
a distended bladder, or forwards by a distended 
rectum. The axis of its cavity is not a straight 
but a curved line; and uterine sounds should be 
shaped to suit it." 



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